Senior Fraud Investigator

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Job Summary

This position is responsible for planning and developing investigation tools and techniques to conduct detailed investigations of potentially fraudulent claim activity by members, employees and providers, both internally and externally initiated, and makes recommendations for prosecution, recovery and litigation. Also, reviews operational controls, and claim system controls and protocols, and recommends enhancements to reduce the potential for fraud.

Job Description

• Performs detailed analysis of claim payment data, prepares analysis and evidentiary reports. Monitors potentially fraudulent claims and suspect billing patterns along with inquiries and other business matters for HCSC and all its subsidiaries and subcontractors.
• Creates special reports for the purpose of identifying potentially fraudulent billing patterns that will require investigation and/or corrective actions. Conducts and supports audits and investigations requiring complex investigative and analysis skills.
• Design, implement and monitor anti-fraud initiatives concerning fraud detection procedures and documentation to increase corporate savings and recoveries on confirmed fraud cases and major abusive billing. Coordinate team activities such as initiating and implementing investigative strategy, problem solving, and decision-making.
• Conduct investigative work so that SID is in compliance with state and federal regulations that govern reporting and investigative work within the MAPD, PDP, Medicaid, and Dual Eligible Programs.
• Recommend enhancements such as prepayment review to limit fraud exposure in the claims processing system in accordance with divisional and departmental policies and procedures.
• Design, implement, and monitor projects concerning proactive fraud detection and procedures documentation to increase corporate savings and recoveries on confirmed fraud, waste, and abuse cases.
• Organize evidence obtained in investigations for presentation to the Assistant U.S. Attorney, State's Attorney, State Attorney General, Federal Bureau of Investigation, Investigations Medicare Drug Integrity Contractor, Local Law Enforcement including the Medicaid Fraud Control Units, State Offices of Inspector General, State Licensing Agencies, HCSC internal departments, and external Attorneys.
• Assist in the preparation of and present SID anti-fraud activity reports for HCSC employer groups.
• Coordinate the activities of SID support personnel and associate and fraud investigators on a case-by-case and project basis and participate in their training and development as it relates to major healthcare and employee investigations, internal/embezzlement and external fraud leads.
• Perform reviews of enterprise, subsidiary, and sub-contractor claim, eligibility, and customer service operations to determine compliance with established corporate/divisional policies and procedures. Recommend enhancements to limit financial exposure related to fraud and abuse for provider, subscriber, group conspiracy and employee/embezzlement.
• Responsible for criminal and civil case development, organization and preparation for cases being forwarded for prosecution or litigation; serve as the primary contact for all civil, criminal, or licensing agency queries for the referred cases.
• Establish internal and field investigations and major investigative techniques for assigned staff. Responsible for the preparation of field audit reports and major case analysis, and case presentation to Federal, State, and civil officials.
• Conduct provider on-site and desk audits and review internal and external projects and programs to reduce the financial risk related to fraudulent activity; and make recommendations on identified internal control issues to reduce the risk of fraud and abuse material losses.
• Act as a project leader on complex investigations requiring activities from multiple staff members; supervise the activities of one or more research analysts.
• Ensure all aspects of a fraud and abuse projects and investigations are in compliance with HIPAA Privacy Requirements.
• Communicate and interact effectively and professionally with co-workers, management, customers, etc.
• Comply with HIPAA, Diversity Principles, Corporate Integrity, Compliance Program policies and other applicable corporate and departmental policies.
• Maintain complete confidentiality of company business.
• Maintain communication with management regarding development within areas of assigned responsibilities and perform special projects as required or requested.

JOB REQUIREMENTS:

• Bachelor's Degree
• 5 years law enforcement experience (local, state, or federal) or 3 health care fraud investigative experience.
• Familiarity with laws applicable to health care fraud.
• Ability to develop effective liaison relations which facilitate case identification, investigation, and prosecution.
• Ability to independently prepare reports of interview and other documentation accurately reflecting investigative activity and results.
• Clear and concise verbal and written communication skills.

PREFERRED REQUIREMENTS:

• Experience working with Excel, PowerPoint, Word and Outlook.
• Accredited Health Care Fraud Investigator
• Certified Professional Coder
• Certified Fraud Examiner
• Knowledge of health care claims processing and benefit administration.

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Pay Transparency Statement:

At Health Care Service Corporation, you will be part of an organization committed to offering meaningful benefits to our employees to support their life outside of work. From health and wellness benefits, 401(k) savings plan, pension plan, paid time off, paid parental leave, disability insurance, supplemental life insurance, employee assistance program, paid holidays, tuition reimbursement, plus other incentives, we offer a robust total rewards package for employees. Learn more about our benefit offerings by visiting https://careers.hcsc.com/totalrewards.

The compensation offered will vary depending on your job-related skills, education, knowledge, and experience. This role aligns with an annual incentive bonus plan subject to the terms and the conditions of the plan.

HCSC Employment Statement:

We are an Equal Opportunity Employment employer dedicated to providing a welcoming environment where the unique differences of our employees are respected and valued. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, protected veteran status, or any other legally protected characteristics.

Base Pay Range
$54,800.00 - $121,100.00