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Healthcare Fraud Investigator

2 months ago

San Francisco, California, United States The Midtown Group Full time
Job Description

Job Title: Financial Analyst

Job Summary:

The Midtown Group is seeking a skilled Financial Analyst to join our team. As a Financial Analyst, you will be responsible for performing data analytics to identify fraud, waste, or abuse in claims data. You will also review and analyze the financial and management operations of various businesses, including proprietorships, commercial, industrial, financial, and other organizations.

Responsibilities:

  • Perform data analytics to identify fraud, waste, or abuse in claims data.
  • Review and analyze the financial and management operations of various businesses, including proprietorships, commercial, industrial, financial, and other organizations.
  • Examine pertinent financial statements, accounting records, operating reports, billing records, invoices, data processing material, and other documents pertaining to the transactions, events, or allegations under investigation.
  • Use financial reports and automated systems to review complex data and transactions.
  • Gather and examine a wide variety of financial documents and other materials from various sources; interview witnesses and suspects; and present findings and conclusions to agents, AUSAs, and supervisors.
  • Use knowledge of healthcare coding conventions, fraud schemes, general areas of vulnerability, reimbursement methodologies, and relevant laws to find suspicious patterns in claims data and other sources.
  • Develop and maintain general knowledge of healthcare reimbursement policies and state and federal regulations related to healthcare fraud and abuse.
  • Work with paralegal specialists, litigation support specialists, and others to compile documents and physical evidence, create detailed charts, graphs, summaries, videotapes, and other audio-visual materials for use in court documents and proceedings, including evidentiary hearings and at trial.
  • Prepare concise interim and final reports on the progress of investigations for use by agents, AUSAs, and supervisory attorneys. Include significant findings and conclusions, recommendations for additional investigative actions, additional avenues of investigation, and assessments of strengths and weaknesses of witnesses and documentary evidence.
  • Maintain security and confidentiality of all materials, including protected health information encountered in performance of duties.

Requirements:

  • Undergraduate degree in accounting, business, economics, finance, or related field of study.
  • Accredited Healthcare Fraud Investigator (AHFI), or similar preferred.
  • Professional Certification as a Certified Fraud Examiner (CFE) preferred.
  • 3 years of experience in Healthcare Fraud Analysis preferred.

Skills and Knowledge:

  • Ability to assess products and procedures for compliance with government standards, accounting principles, and multi-tiered system application standards.
  • Knowledge of financial analysis for individuals, healthcare-related companies, and partnerships, including review of financial statements and bank records.
  • Possesses an understanding of the budget allocation, execution, and administration process.
  • Knowledge of debt collection techniques, including garnishment, execution, and appointment of receivers.
  • Able to monitor and track obligation and expenditure of funds, detect, reconcile and remedy fiscal discrepancies, and provide cost-effective, insightful reporting to decision makers.
  • Familiarity with activity-based costing, business case analysis, and outsourcing requirements.
  • Cognizant of interrelationships between financial management requirements and automated solutions, considering the current system environment and the potential integration of added systems concurrently or later.
  • Ability to develop work breakdown structures and prepare charts, tables, graphs, and diagrams to assist in analyzing problems.
  • Familiarity with computer systems and demonstrated proficiency with online computer databases, EXCEL and ACCESS, and similar commercial database programs.