Remote Healthcare Fraud Investigator II | WFH

Job Overview

As a Fraud Investigator II in the healthcare sector, you will assume a critical position in combating fraud, waste, and abuse (FWA) within the Medicaid program. This role, reporting directly to the Associate Director or their delegate, involves conducting comprehensive investigations to detect and rectify atypical billing practices and trends. Your responsibilities will encompass... extensive research, data scrutiny, and collaboration on intricate cases.

Key Responsibilities
? Leverage your extensive knowledge of federal and state regulations as well as healthcare industry standards to inform your investigative work.
? Employ data mining and analytical techniques to detect inconsistencies in claims data and identify emerging trends indicative of potential FWA.
? Design algorithms, execute queries, and generate reports aimed at uncovering possible fraudulent activities.
? Review member records and claims to ensure they comply with relevant regulations, contractual obligations, and organizational policies.
? Compile and document investigative outcomes, calculate overpayments, and present findings in accordance with company protocols.
? Maintain thorough documentation of your investigations and audit results based on established performance criteria.
? Engage with providers to relay audit findings, discuss recoveries, and deliver educational insights.
? Propose enhancements to policies, procedures, and systems to improve the efficacy of investigative efforts.
? Conduct meticulous assessments of compliance with Medicaid regulations through detailed examination of records.
? Mentor Investigator I staff by aiding them in identifying and addressing fraudulent phenomena.
? Act as a resource for various departments to resolve integrity-related inquiries.
? Keep management informed on the status of investigations and advocate for initiatives such as the implementation of advanced algorithms.
? Manage and document cases to ensure precision and timeliness in all reporting.

Required Skills
? Comprehensive understanding of federal and state regulations and healthcare industry standards.
? Proficient analytical, problem-solving, and root-cause analysis capabilities.
? Expertise in data mining and analysis methodologies.
? Strong customer service orientation and professionalism when interacting with providers and colleagues.
? Ability to manage multiple priorities and tasks independently in a high-pressure environment.
? Excellent communication skills, both written and verbal.
? Familiarity with medical auditing principles and practices.

Qualifications

Required:
? Bachelor's degree in Business Administration, Finance, Public Health, or a related field, or equivalent experience.
? A minimum of 5-7 years relevant experience in fraud examination, healthcare, business, or finance, including at least 2 years concentrated on data mining and claims within the healthcare insurance sector.
? Solid grasp of coding, reimbursement, and claims processing policies.
? Knowledge of fraud-related laws and regulations.
? Proven ability to produce high-quality, detail-oriented deliverables.
? Proficient in Microsoft Office applications (Word, Excel, PowerPoint, Access).

Preferred
? Master's degree in Business Administration or Public Health.
? Relevant certifications such as CFE, CPA, RN/LPN, CPC, or CPMA.
? Advanced skills in Microsoft Excel.
? Familiarity with state and federal regulations concerning public assistance programs.
? Strong decision-making capabilities, able to analyze options and select the best course of action.
? Creative analytical skills, with an ability to pose insightful questions and drive process enhancements.

Career Growth Opportunities

This position offers significant prospects for professional development and career advancement within a reputable organization dedicated to maintaining the integrity of the Medicaid program. You will gain valuable experience, expand your skill set, and build a professional network that can facilitate future opportunities.

Company Culture And Values

We pride ourselves on fostering an inclusive and supportive work environment that values diversity and collaboration. Our commitment to integrity, excellence, and community service drives our business and shapes our company culture, making it an ideal place for professionals who are passionate about making a difference.

Networking And Professional Opportunities

Joining our team presents opportunities for networking and collaboration with industry experts and thought leaders. You will be part of an established professional network that emphasizes continuous learning and knowledge sharing.

Employment Type: Full-Time

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