Investigations and Compliance Professional

6 days ago


Baltimore, Maryland, United States Cynet Systems Full time
Job Summary

Cynet Systems is seeking a highly skilled Investigations and Compliance Professional to join our Special Investigations Unit. As a key member of our team, you will be responsible for conducting thorough investigations and providing support to identify and prevent fraud, waste, and abuse within our organization.

Key Responsibilities
  • Conduct independent investigations and provide support to identify and prevent fraud, waste, and abuse.
  • Develop and execute investigative plans to analyze financial business records, provider and subscriber medical data, claims, and other relevant documents.
  • Provide support for offsite audits and investigations, as well as interviews with stakeholders.
  • Research and analyze claims data using company anti-fraud software, Excel, and other tools to identify potential cases.
  • Develop documentation to substantiate findings, including formal reports, spreadsheets, graphs, and audit logs.
  • Ensure timely maintenance and organization of case file documentation, with a high level of detail and accuracy.
  • Initiate claim adjustments, voucher deducts, and voluntary refunds to recover funds.
  • Record recoveries and savings following established processes.
  • Perform special projects as assigned by management to meet the needs of the Special Investigations Unit.
Requirements
  • Bachelor's Degree.
  • 2 years of experience in insurance, investigative, health care, nursing, or law enforcement.
  • In lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience.
Preferred Qualifications
  • Credential in a health care or investigations related area, such as Certified Fraud Examiner (CFE).
  • Accredited Health Fraud Investigator (AHFI), RN/LPN, or Certified Professional Coder (CPC).
  • Knowledge of ICD 10 and CPT Codes, medical terminology, extensive training in claims and subscriber customer service methods, and previous experience in the health care industry.
Knowledge, Skills, and Abilities
  • Knowledge of laws that pertain to public and insurance funds.
  • Excellent communication skills, both written and verbal.
  • Ability to recognize, analyze, and solve a variety of problems.
  • Ability to maintain effective interpersonal relationships.


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