Summary of Position

Conduct complex, in-depth investigations of reported fraud involving the full range of healthcare products.
Provide guidance to the Fraud Investigators conducting anti-fraud training sessions and public speaking engagements.
Review medical records with clinical interpretation for investigative review.
Review claims data and medical documentation to ensure proper coding of claims.

Principal Accountabilities

Investigate complex cases of reported fraud involving the Company's full range of healthcare products.
Develop leads from various sources to review for suspect activity.
Review claim files and develop action plans for the investigation.
Conduct highly comprehensive interviews/interrogations with providers.
Perform various related duties as assigned: conduct medical records assessments, CPT coding issues, etc.
Provide in depth review of medical records as it relates to investigations of fraud waste and abuse for leadership and
peer case review.
Provide review and assessment of coding on claims data and medical documentation to ensure it is accurate per
diagnosis or conditions outlined in medical files.
Establish and maintain liaisons with law enforcement, regulatory agencies, and with industry peers.
Refer cases to law enforcement agencies/escalate to appropriate internal channels as needed.
Conduct fraud awareness training sessions and public speaking engagements. Provides guidance to the Fraud
Investigators.

Education, Training, Licenses, Certifications

Bachelor's degree in Criminal Justice or related field
Certified Coder
Nursing License (LPN; RN preferred).

Relevant Work Experience, Knowledge, Skills, and Abilities

4 - 6+ years of relevant, professional work experience. (R)
3+ years of professional investigation experience with a law enforcement agency. (R)
Strong knowledge of CPT and ICD9-CM coding, medical terminology, and treatment options. (R)
Working knowledge of applicable laws/regulations. (R)
Strong communication skills (verbal, written, interpersonal) with all types/levels of audience. (R)
Proficiency with MS Office (Word, Excel, PowerPoint, Outlook, Teams, etc.). (R)
Detail oriented; highly organized; ability to maintain discretion at all times. (R)
Ability to successfully manage multiple tasks simultaneously with competing priority levels and deadlines. (R

Additional Information

Requisition ID: 1000000461