Special Investigations Unit

2 weeks ago

Baltimore, United States nTech Solutions, Inc. Full time

Terms of Employment

  • Contract, 6 Months
  • This position can either be 100% remote or hybrid – with candidates working a few days onsite in the Baltimore, MD or Owings Mills, MD office.
  • Candidates interested in remote work must reside in the Eastern Time Zone.

Overview
Our client is seeking to hire six (6) Special Investigations Unit (SIU) Investigators to join their team. The role of the SIU Investigators is to assist in the reduction and recuperation of losses through the detection, investigation, and resolution of low to medium levels fraud, waste, and abuse schemes orchestrated by providers, members, brokers, or internal employees, resulting in the savings and recovery of funds. The SIU Investigators will be responsible for conducting preliminary investigations into members that are suspected of committing fraud when enrolling for health insurance. This will include researching and analyzing member data and documentation, compiling this research into a report, and ultimately generating templated letters to send to the suspected violating members to attempt to determine if fraud is occurring. General responsibilities include:

  • Independently conduct low to medium level investigations and provide support as part of an assigned team to all levels (low to medium) investigations of suspected fraud, waste, and abuse.
  • In conjunction with assigned team or management, develop and execute investigative plans that may include performance of audits of financial business records, provider and subscriber medical data, claims, systems’ reports, medical records, analysis of contract documents, provider/subscriber claims history, benefits, external data banks and other documents to determine the possible existence of fraud.
  • Provide support for offsite audits/investigations and interviews when requested.
  • Research provider/subscriber claims activity, operations manuals, data systems, medical policies, job duties and group benefit contracts to identify control deficiencies and non-compliance.
  • Develop documentation to substantiate findings including formal reports, spreadsheets, graphs, audit logs, use of anti-fraud software and appropriately sourced reference materials.
  • Ensure audits and investigations are timely, effective and result in an overall achievement of unit goals.
  • Researches and analyzes claims data using company anti-fraud software, Excel, and other tools to proactively identify new potential cases.
  • Develop documentation that supports conclusions, recommendations, and substantiates findings including formal correspondence, audit reports, spreadsheets, graphs, audit logs, anti-fraud software analysis, and appropriately sourced reference materials.
  • Ensures timely maintenance and organization of case file documentation with a high level of detail and accuracy that clearly and concisely outlines investigative steps, case synopsis, and findings and to preserve as potentially discoverable material.

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