- Investigate alleged healthcare fraud, waste, and abuse by researching offenses, reviewing records, conducting interviews, and collecting evidence.
- Analyze findings to determine whether allegations are substantiated and develop corrective actions or referrals with colleagues and subject matter experts.
- Develop, document, and maintain case files, including timely updates in databases and case-tracking tools.
- Research Medicare and Medicaid claims data and other sources to establish applicable policy requirements.
- Prepare investigative reports applying relevant federal or state laws, rules, and regulations.
- Coordinate joint investigations, case development, and information sharing with internal teams, law enforcement, legal counsel, CMS, and government investigators.
- Research suspect providers for adverse business relationships, sanctions, exclusions, or other disqualifying information.
- Analyze claims data for patterns or anomalies indicating fraud, waste, and abuse, and contribute to fraud-detection methodologies.
- Respond to law enforcement and client requests for data, documentation, and investigative support.
- Review and approve administrative action requests, maintain related statistics and templates, and conduct on-site visits and in-person interviews when required.
Data Analysis