Job Description
General Summary:
As a Fraud Investigator II, you'll play a pivotal role in tackling fraud, waste, and abuse (FWA) within the Medicaid program. Reporting to the Associate Director or their designee, you will conduct thorough investigations to identify and address unusual billing practices and patterns. Your work will involve in-depth research, data analysis, and collaboration on complex cases.
You will also have the opportunity to mentor other investigators, sharing your expertise on detecting provider schemes and ensuring compliance with federal and state regulations. With increasing responsibility, you'll manage multiple provider types and lead investigative efforts within the team.
Responsibilities:
Apply comprehensive knowledge of federal and state regulations and healthcare industry standards to your investigations.
Utilize data mining and analysis techniques to identify irregularities in claims data and develop trends for potential FWA cases.
Create algorithms, queries, and reports to uncover possible fraudulent activities.
Review member records and claims to ensure they align with applicable regulations, contracts, and policies.
Compile and document investigative findings, calculate overpayments, and report results in line with organizational policies.
Maintain detailed documentation of your work and audit results based on established standards.
Communicate with providers to discuss audit findings, recoveries, and provide educational feedback.
Suggest improvements to policies, procedures, and systems to enhance investigative effectiveness.
Assess compliance with Medicaid regulations through meticulous examination of records.
Support Investigator I staff by guiding them in recognizing and addressing fraudulent patterns.
Serve as a resource for departments to address and resolve integrity inquiries.
Keep internal management updated on investigation progress and propose new initiatives such as advanced algorithms.
Manage and track cases within the system to ensure accuracy and timeliness.
Perform additional duties as needed to support the team.
Qualifications:
Required:
Bachelor's degree in Business Administration, Finance, Public Health, or a related field, or equivalent experience.
5-7 years of relevant experience in fraud examination, healthcare, business, or finance, with at least 2 years focused on data mining and claims in the healthcare insurance industry.
Understanding of coding, reimbursement, and claims processing policies.
Familiarity with medical auditing principles and practices.
Strong analytical, problem-solving, and root-cause analysis skills.
Knowledge of fraud-related laws and regulations.
Proven track record of producing high-quality, detail-oriented work.
Ability to manage multiple tasks, set priorities, and work independently under pressure.
Proficiency in Microsoft Office applications (Word, Excel, PowerPoint, Access).
Excellent customer service skills with a professional demeanor when interacting with providers and staff.
Strong interpersonal and communication skills, both oral and written.
Preferred:
Master's degree in Business Administration or Public Health.
Relevant certifications or licensure such as CFE, CPA, RN/LPN, CPC, or CPMA.
Advanced skills in Microsoft Excel.
Knowledge of state and federal regulations related to public assistance programs.
Strong decision-making abilities with a knack for evaluating options and choosing the best course of action.
Creative thinking skills with the ability to ask insightful questions and drive process improvements.
Employment Type: Full-Time
Salary: $ 80,000.00 Per Year
Job Tags
Full time, Remote job,