Job Description

A bit about this role: The Senior Investigator, Special Investigations will play a crucial role in investigating allegations of healthcare fraud, waste, and abuse. This position is responsible for planning, organizing, and executing complex and specialized investigations or audits aimed at preventing, detecting and responding to potential fraudulent activities to protect our members and the Medicare Fund. Your Responsibilities and Impact will include:

• Perform data mining and analysis to detect aberrancies and outliers in claims, medical records, enrollment records, or other relevant healthcare transactions; independently researches FWA issues and effectively employs investigative resources/techniques.
• Handle complex investigations that require advanced investigative knowledge/skills.
• Acts as subject matter expert for SIU Investigator(s), providing specialized knowledge and guidance.
• Mentor and assist with training SIU staff and internal business partners. Assist in the development and presentation of FWA training.
• Assist in development of policies and procedures related to fraud, waste, and abuse detection and investigation. Support the development and execution of the annual SIU risk assessment and work plan.
• Conduct provider education in response to investigations and audits.
• Refer issues to the appropriate parties (e.g., regulators, law enforcement); ensuring comprehensive summary and detailed reports on investigative findings for referral to federal and state agencies are in compliance with regulatory requirements.
• Responsible for creating and presenting FWA reports to Senior leaders, including summarizing identified trends and patterns indicative of potential FWA with recommendations for prospective and retrospective detection, investigation, recovery and avoidance programs.
• Serve as the primary point of contact for corporate and field inquiries regarding fraud, waste, and abuse. Collaborate with relevant stakeholders to facilitate the recovery of funds and/or any other internal actions deemed necessary and appropriate in the resolution of detected FWA (e.g., contract termination, education).
• Collaborate with and provide regular updates on current FWA schemes, progress of investigations and coordinate with internal stakeholders on recommendations, actions, and resolutions (e.g., FWA Monthly Workgroup, Market/Network, Credentialing Committee, FWA Subcommittee).
• Arrange, conduct, and participate in meetings with providers, business partners, and representatives from regulatory agencies and law enforcement regarding ongoing investigations. Participate in OIG Healthcare Fraud Workgroups.
• Lead investigations into Agent Broker allegations of fraudulent behavior.

Required skills and experience:

• Bachelor’s Degree in Business, Criminal Justice, Healthcare, or a related field, or equivalent experience.
• A minimum of 3 years of experience in health insurance fraud investigation
• Experience in Medicare and/or Medicaid programs, specifically with medical claim billing, reimbursement, audit, or provider contracting.
• Demonstrated Experience with conducting internal employee investigations and investigations involving contracted sales agents and agencies.
• Experience with data analysis techniques and AI concepts for business processes.

Desired skills and experience:

• Strong analytical skills with the ability to interpret complex data sets.
• Excellent written and verbal communication skills for report writing and stakeholder engagement.
• Detail-oriented with a strong commitment to integrity and compliance.
• Ability to work independently and collaboratively in a fast-paced environment.
• Strong organizational skills and the ability to manage multiple investigations simultaneously.

Licenses/Certifications :

• Certified Fraud Examiner (CFE) and/or Certified Professional Coder (CPC) certification is preferred.

Salary range: $75,000 - $110,000 / year The pay range listed for this position is the range the organization reasonably and in good faith expects to pay for this position at the time of the posting. Once the interview process begins, your talent partner will provide additional information on the compensation for the role, along with additional information on our total rewards package. The actual base salary offered will depend on a variety of factors, including the qualifications of the individual applicant for the position, years of relevant experience, specific and unique skills, level of education attained, certifications or other professional licenses held, and the locat