Special Investigations Unit Investigator

4 days ago


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

Cynet Systems is seeking a highly skilled and detail-oriented Investigations Specialist 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 and abuse within our organization.

Key Responsibilities
  • Investigations and Analysis
    • Conduct independent investigations and provide support to identify and prevent fraud and abuse.
    • Develop and execute investigative plans to identify potential cases of fraud and abuse.
    • Analyze claims data using company anti-fraud software, Excel, and other tools to proactively identify new potential cases.
  • Documentation and Reporting
    • Develop documentation to substantiate findings, including formal reports, spreadsheets, graphs, audit logs, and use of anti-fraud software.
    • Ensure timely maintenance and organization of case file documentation with a high level of detail and accuracy.
  • Claim Adjustments and Recoveries
    • Initiate claim adjustments, voucher deducts, and voluntary refunds to recover funds.
    • Record recoveries and savings following established processes.
  • Special Projects
    • Perform special projects as assigned by management to meet the needs of the Special Investigations Unit.
Requirements
  • Education
    • Bachelor's Degree.
  • Experience
    • 2 years insurance, investigative, health care, nursing, or law enforcement experience.
    • 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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