Investigator
New
I
Integrity Management Services, Inc.Healthcare investigations
U.S. remoteFull-TimeSenior
Salary50,000 - 70,000 USD per year
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Job Details
- Experience
- 5-7 years experience; 6+ years investigative experience in the Healthcare industry; at least 3 years of experience in benefit integrity investigation/detection or a related field
- Required Skills
- Data Analysis
Requirements
- Bachelor degree in business or a related field.
- 5-7 years of experience in a related field such as law enforcement investigation, statistics, or data analysis.
- 6+ years of investigative experience in the healthcare industry.
- At least 3 years of experience in benefit integrity investigation/detection or a related field involving information review, analysis or development, and decision-making.
- Knowledge of the CMS Medicare Program Integrity Manual, Chapter 3 – Verifying Potential Errors and Taking Corrective Actions.
- Strong investigative skills and advanced data analysis skills.
- Knowledge of medical terminology, ICD-9-CM, ICD-10-CM, HCPCS Level II, and CPT codes.
- Experience reviewing claims for billing and medical coding requirements, performing medical review, and/or developing fraud cases.
- CFE or AHFI certification preferred.
- Wired and/or wireless internet access is required for remote work.
- Must pass post-hire background screening checks.
Responsibilities
- 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.
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