Healthcare Fraud Investigator

2 weeks ago

Atlanta, Georgia, United States CareSource Full time
Job Summary:

The SIU Investigator III is a critical role within the Special Investigations Unit at CareSource, responsible for investigating and resolving high-complexity allegations of healthcare fraud, waste, and abuse (FWA) by medical professionals, facilities, and members. This position requires a strong analytical mindset, excellent research skills, and the ability to work independently with minimal supervision.

Key Responsibilities:
  • Develop and coordinate strategic fact-driven investigative projects, including business process reviews, execution of investigative activities, and development of investigation outcome recommendations.
  • Manage the development, production, and validation of reports generated from detailed claims, eligibility, pharmacy, and clinical data, and translate analytical findings into actionable items.
  • Manage strategic investigative plans and drive investigative outcomes for the team.
  • Ensure quality outcomes for the investigative team through auditing and oversight.
  • Prioritize, track, and report the status of investigations.
  • Report identified corporate financial impact issues.
  • Utilize concepts and knowledge of coding guidelines to analyze complex provider claim submissions.
  • Research, comprehend, and interpret various state-specific Medicaid, federal Medicare, and ACA/Exchange laws, rules, and guidelines.
  • Identify, research, and comprehend medical standards, healthcare authoritative sources, and apply knowledge to investigative approaches.
  • Collaborate with data analytics teams and utilize RAT STATS on Statistically Valid Random Sampling.
  • Coordinate on-site and desk audits of medical record reviews and claim audits.
  • Manage and decide claims pending for investigative purposes.
  • Maintain a working knowledge of all state and federal laws, rules, and billing guidelines for various provider specialty types.
  • Prepare and conduct in-depth complex interviews relevant to investigative plans.
  • Execute and manage provider formal corrective action plans.
  • Participate in meetings with operational departments, business partners, and regulatory partners to facilitate investigative case development.
  • Participate in meetings with Legal General Counsel to drive case legal actions, formal corrective actions, negotiations with recovery efforts, settlement agreements, and preparation of evidentiary documents for litigation.
  • Develop regulatory fraud, waste, and abuse reports to federal and state Medicare/Medicaid agencies.
  • Manage and maintain sensitive confidential investigative information.
  • Present, support, and defend investigative research to seek approval for formal corrective actions.
  • Establish and maintain relationships with Federal and State law enforcement agencies, task force members, other company SIU staff, and external contacts involved in fraud investigation, detection, and prevention.
  • Serve as a subject matter expert in the designated market and apply external intelligence to analysis and case development.
  • Develop and present internal and external formal presentations.
  • Attend fraud, waste, and abuse training/conferences.
  • Maintain compliance with state and federal laws and regulations, and contracts.
  • Adhere to the CareSource Corporate Compliance Plan and the Anti-Fraud Plan.
  • Assist in Federal and State regulatory audits as needed.
Requirements:
  • Bachelor's Degree or equivalent years of relevant work experience in a Health-Related Field, Law Enforcement, or Insurance required.
  • Master's Degree (e.g., criminal justice, public health, mathematics, statistics, health economics, nursing) preferred.
  • Minimum of five (5) years of experience in healthcare fraud investigations, medical coding, pharmacy, medical research, auditing, data analytics, or related fields required.
Competencies, Knowledge, and Skills:
  • Intermediate proficiency level in Microsoft Office to include Outlook, Word, Excel, Access, and PowerPoint.
  • Effective listening and critical thinking skills and the ability to identify gaps in logic.
  • Strong interpersonal skills, high level of professionalism, integrity, and ethics in performance of all duties.
  • Excellent problem-solving and decision-making skills with attention to details.
  • Background in research and drawing conclusions.
  • Ability to perform intermediate data analysis and articulate understanding of findings.
  • Ability to work under limited supervision with moderate latitude for initiative and independent judgment.
  • Ability to manage demanding investigative case loads.
  • Ability to develop, prioritize, and accomplish goals.
  • Self-motivated, self-directed.
  • Strong written skills with the ability to compose detailed investigative reports and professional internal and external correspondences.
  • Presentation experience.
  • Knowledge of Medicaid, Medicare, healthcare rules preferred.
  • Background in medical terminology, CPT, HCPCS, ICD codes, or medical billing preferred.
  • Complex project management skills preferred.
  • Display leadership qualities.
Licensure and Certification:
  • Accredited Healthcare Fraud Investigator (AHFI) or Certified Fraud Examiner (CFE), and Certified Professional Coder (CPC) certifications are required.
  • NHCAA or other fraud and abuse investigation training is preferred.
Working Conditions:
  • General office environment; may be required to sit or stand for extended periods of time.
  • Occasional travel (up to 10%) to attend meetings, training, and conferences may be required.
Compensation Range:

$69,000.00 - $111,000.00

CareSource takes into consideration a combination of a candidate's education, training, and experience as well as the position's scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. We are highly invested in every employee's total well-being and offer a substantial and comprehensive total rewards package.

Compensation Type: Salary

Competencies: Create an Inclusive Environment, Cultivate Partnerships, Develop Self and Others, Drive Execution, Influence Others, Pursue Personal Excellence, Understand the Business

This job description is not all-inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer, including disability and veteran status. We are committed to a diverse and inclusive work environment.

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