Investigator II

About This Role

This role is responsible for identifying, investigating, and developing cases against perpetrators of healthcare fraud to recover corporate and client funds paid on fraudulent claims. This role requires associates to be in-office 1-2 days per week, fostering collaboration and connectivity.

Responsibilities

• Conduct claim reviews for appropriate coding, data mining, and entity review using proprietary data and claim systems for facility, professional, and pharmacy claims
• Identify and develop enterprise-wide specific healthcare investigations potentially impacting multiple health plans or lines of business
• Establish and maintain rapport and working relationships with law enforcement
• Interface with senior level management and the legal department throughout the investigative process
• Assist in training internal and external entities
• Assist in the development of policy and/or procedures to prevent loss of company assets

Requirements

• BA/BS degree or equivalent experience
• Minimum of 3 years related experience

Qualifications

• BA/BS or equivalent combination of education and experience
• 3+ years related experience

Nice to Have

• Fraud certification (CFE, AHFI, AAPC or coding certificates)
• Knowledge of Plan policies and procedures in benefit programs management with heavy emphasis in negotiation
• Health insurance experience
• Law enforcement experience

Benefits