Special Investigations Unit (SIU) Investigator-1 year healthcare fraud experience

Purpose of the job

• Prevents, detects, and deters fraud, waste, and abuse against Commercial, Government (FEP and Medicare) and Part D Programs, resulting in maximum plan value returned back to plan. Provides the SIU with support for day-to-day operations including investigations, analysis, management, and special projects.

REQUIRED QUALIFICATIONS

Required Work Experience (All Levels)

• 1 year of experience in healthcare related fraud investigations, and / or data mining/analysis

Required Education (All Levels)

• High School Diploma or GED in general field of study

Required Licenses

• N/A

Required Certifications

• N/A

PREFERRED QUALIFICATIONS

Preferred Work Experience (All Levels)

• 3 -5 years(s) of experience in healthcare related fraud investigations, data mining/analysis and/or complex projects
• Medical coding and/or billing
• Strong understanding of health insurance reimbursement methodologies, including working knowledge of current medical claim coding requirements (i.e., diagnosis and procedure codes)

Preferred Education (All Levels)

• Bachelors Degree in business, healthcare administration, accounting, nursing, criminal justice or related field

Preferred Licenses

• N/A

Preferred Certifications

• Accredited Health Care Fraud Investigator (AHFI)
• Certified Fraud Examiner (CFE)
• Certified Professional Coder (CPC)
• Certificates/designations and/or advanced training in healthcare fraud and abuse investigations

ESSENTIAL job functions AND RESPONSIBILITIES

Level 1

• Accurately triage and assess disposition of referrals.
• Research and investigate allegations of fraud, waste and abuse to prevent, detect and deter resulting in maximum plan value (front-end savings, recoveries, projected savings) returned back to plan; using the following tools but not limited to, claims processing systems, medical coverage guidelines, payment policies and member/group benefits and provider contracts.
• Utilize data mining techniques, statistical data analysis, and analytical software to identify potential fraud, waste, and abuse against all Programs.
• Seek out and develops leads and cases received from sources including fraud alerts, government and private sources.
• Develop summary reports that explain key findings in data evaluation.
• Develop and implement corrective action plans
• Incorporate critical thinking skills and judgment in analysis process to determine best course of action for each tip/case.
• Escalate high risk and/or tip & case issues to management
• Perform investigations, such desk top and on-site medical record audits, surveillance, undercover work, suspect & witness interview.
• Prepare cases for referral to law enforcement officials for prosecution
• Testify and give depositions as an expert witness in legal proceedings.
• Maintain chain of custody on all documents, documenting all stages of each investigation.
• Create, update and follow standard departmental operating procedures, policies, confidentiality and security guidelines.
• Develop materials and assist with fraud, waste, and abuse training for internal and external audiences.
• Attend seminars / webinars annually to stay current on fraud, waste, and abuse trends and issues.
• Participate in corporate task teams as deemed appropriate.

Level 2

• Work on investigations and projects of greater complexity and responsibility by developing report queries and evaluate data integrity to identify patterns and trends and data aberrancies/schemes to evaluate investigative findings.
• Provide technical support and guidance to less experienced team members.
• Perform all responsibilities of the position with minimal need for supervision or training.
• Represent Corporate Integrity on teams to develop, test and implement software, databases or to create and maintain other reliable method of tracking and reporting referrals, hotline calls and fraud training.

Level 3

• Act as primary contact for initiating and coordinating projects with other business units.
• Maintain technical aspects of fraud information/reporting methods (e.g.: forms, flyers and database reporting).
• Develop, maintain and manage SIU case tracking system and design and generate trend analysis reports.
• Write and understand queries to pull fraud waste and abuse activity proactively from a data mart.
• Provide day-to-day support and training to investigative team.
• Support management requests for various reporting requirements.
• Create accurate reports for internal / external reporting requirements, including BCBSA.
• Coordinate post-payment claims review by external vendors.
• Perform quality audits of closed tip and cases work from Investigators.

ALL Levels

• Each progressive level includes the ability to perform the essential functions of any lower levels.
• The position requires a full-time work schedule. Full-time is defined as working at least 40 hours per week, plus any additional hours as requested or as needed to meet business requirements.
• Perform all other duties as assigned.