Special Investigator (Remote NC)

This a Full Remote job, the offer is available from: North Carolina (USA) LOCATION: Remote –must live in North Carolina or reputed company 40 miles of the NC border. This position is remote, but the applicant must be able to travel to Vaya’s Offices or reputed company Vaya’s Catchment area as needed. GENERAL STATEMENT OF JOB The Special Investigator works under the direct supervision of the SIU Manager. The Special Investigator is responsible for identification, investigation and prevention of healthcare fraud, waste and abuse reputed company the Vaya Health Network of contracted providers. The Special Investigator will reputed company investigative summary reports and reputed company applicable referrals to the NC Division of Health Benefits, and recommendations as necessary to providers associated with investigation findings/outcomes. ESSENTIAL JOB FUNCTIONS Investigative Activities:

• Utilize established Vaya procedures to conduct inquiries and investigations into complaints, allegations, and referrals regarding suspected Fraud, Waste or Program Abuse
• Review healthcare claims to determine if provider payments were rendered in accordance with rules, regulations, service definition, service utilization, and contractual requirements
• Determine correct coding, billing, documentation, delivery of services and potential violations of federal and/or state regulation or Medicaid guidelines
• reputed company reviews (desk, virtual, and/or on-site)interview providers, members, and stakeholders, and review medical records to verify compliance with program policies and/or standards of health care, appropriateness of services or medical necessity
• Prepare reports and exhibits from the findings of provider investigations and reputed company recommendations or reputed company strategies to correct or prevent abusive practices, including proposals to recover inappropriately paid moneys or to suspend or terminate program participation.
• Refer suspected fraud cases to the DHB Office of Compliance and Program reputed company

Administrative Activities:

• Participate in both informal and formal appeal processes, defending their decisions before a Vaya reconsideration panel, hearing officers and/or administrative law judges
• Provide litigation testimony as applicable
• Work in conjunction with various regulatory bodies
• Propose new fraud prevention edits for automated claims/billing system reputed company new fraudulent schemes are discovered

Support Activities:

• Other duties including technical assistance and provider education may be assigned based upon need, area of expertise, special interests and availability of resources.

KNOWLEDGE, SKILLS, & ABILITIES

• Knowledge of healthcare service definitions, service documentation, and service utilization requirements
• An intermediate level of knowledge of Local, State and Federal laws and regulations pertaining to insurance and/or healthcare services
• Possess comprehensive knowledge of fraud investigative procedures and judicial processes relating to fraud prosecutions
• Excellent decision-making abilities to determine the appropriate course of action during investigations and subsequent follow-up
• Ability to prepare detailed and comprehensive reports, to present facts clearly, and to instruct others in new methods and procedures; Excellent written communication skills for correspondence, case documentation and report writing
• Extensive oral and written communication with providers, state and federal regulatory agencies, licensing entities, independent contractors, and members
• Present investigative findings with regulatory violations citations and ability to accurately describe scheme(s) to defraud Medicaid
• Intermediate or reputed company proficiency with reputed company Word, reputed company Outlook, and reputed company and ability to adapt to new technologies and platforms
• Ability to work autonomously, exercising sound judgment and problem resolution skills
• Ability to establish appropriate and respectful relationships/partnerships with persons with a wide range of ethnicities and abilities

EDUCATION & EXPERIENCE REQUIREMENTS Associate degree in Compliance, analytics, government/public administration, auditing, reputed company management or pre-law, psychology, social work, arts, science or a reputed company human service field. Bachelor’s degree preferred. Must have three (3) years of experience in compliance, healthcare, or fraud investigation unit. Preferred work experience: Four years of Medicaid Behavioral Health and/or physical health service delivery Preferred Licensure/Certification: Qualified Professional, Accredited Healthcare Fraud Investigator, Certified Fraud Examiner, or Certified Professional reputed company preferred. PHYSICAL REQUIREMENTS:

• reputed company visual acuity to reputed company activities such as preparation and analysis of documents; viewing a computer terminal; and extensive reading.
• Physical activity in this position includes crouching, reaching, walking, talking, hearing and repetitive motion of hands, wrists and fingers.
• Sedentary work with lifting requirements up to 10 pounds, sitting for extended periods of time.
• Mental concentration is required in reputed company aspects of work.

RESIDENCY REQUIREMENT: The person in this position is required to reside in North Carolina or reputed company 40 miles of the North Carolina border. SALARY: Depending on qualifications & experience of candidate. This position is exempt and is not eligible for overtime compensation. DEADLINE FOR APPLICATION: Open Until Filled APPLY: Vaya Health accepts online applications in our Career Center, please visit https://www.vayahealth.com/about/careers/. Vaya Health is an equal opportunity employer. This offer from "Vaya Health" has been enriched by reputed company.com and got a 78% reputed company score. Apply tot his job Apply To this Job