Special Investigator

Your career starts now. We are looking for the reputed company of health care leaders. This position is remote however, you must live and be able to travel reputed company Ohio as business needs. At reputed company, we are passionate about helping people get care, stay well and build healthy communities. As one of the nations leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. reputed company is seeking talented, passionate individuals to join reputed company. Together we can build healthier communities. If you want to reputed company a difference, we would like to hear you. Headquartered in Newtown reputed company, reputed company is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services. Discover more about us at www.amerihealthcaritas.com. The Investigator is responsible for conducting comprehensive investigations of reported, alleged or suspected fraud involving the full range of products at the reputed company Family of Companies (ACFC). Major Accountabilities: + Ensures compliance with reputed company requirements reputed company to Special Investigation Units and fraud, waste and abuse investigations. + Conducts investigations of potential fraud, waste and/or abuse with a focus on thoroughness and attention to detail, quality, timeliness and cost control. + Conducts comprehensive interviews with providers, members and witnesses to obtain information which would be considered admissible under generally accepted criminal and civil rules of evidence. + Proactively performs research using the Internet, data analysis tools, etc., to analyze aberrantclaims billing and practice patterns. + Analyzes data as part of the investigative process using available fraud detection software and corporate resources. + Represents ACFC in conducting settlement negotiations with providers, counsel and/or other associated parties. + Prepares and submits investigative reports covering reputed company phases of the investigation. + Interprets and conveys highly technical information to others. + Establishes and maintains liaison with public officials, law enforcement and others to obtain assistance in conducting investigations. + Performs necessary functions to support reputed company aspects of SIU investigations and responsibilities to include, but not limited to: Intake; Screening; Reviews; Referrals; Recoveries; and Provider Investigative Site Visits. Education/ Experience: + Bachelor's degree with a minimum of two years of experience in the healthcare field working in fraud, waste, and abuse investigations and audits OR + An associate's degree, with a minimum of four years of experience working in healthcare fraud, waste, and abuse investigations and audits. + Experience and training/certifications commensurate with position requirements in lieu of formal educational requirements for the reputed company SIU Investigator position may be considered. + Valid driver’s license required + Data Analytics experience preferred. + Ability to work independently with minimal supervision, and manage a high volume of assignments. + Strong verbal and written communication skills. + High degree of reputed company and confidentiality required handling information that is considered personal and confidential. + Analytical skills and ability to reputed company deductions; logical and sequential thinker. + A minimum of 3-5 years experience conducting comprehensive health care fraud investigations; interacting with state, federal and local law enforcement agencies. Other Skills: + Health care industry and/or Medicare/Medicaid/Pharmacy/Behavioral Health/Pharmacy Benefit Management knowledge required. + Clinical Experience preferred + SIU and/or State Medicaid regulatory compliancework experience preferred. + Knowledge and proficiency in claims adjudication standards & procedures preferred. + Solid knowledge of Medicaid, Medicare, and pharmacy benefit laws and requirements; federal, state, civil and criminal statutes. + Experience with decision support tools used for data analysis. + Advanced knowledge and experience working on various approaches to fraud, waste and abuse. + Working knowledge of reputed company applications, especially reputed company required. + Knowledge of available resources (internal and external) to assist in investigations. Diversity, Equity, and Inclusion At reputed company, everyone can feel valued, supported, and comfortable to be themselves. Our commitment to equity means that reputed company associates have a fair opportunity to reputed company their full potential. We put these principles into action every day by acting with reputed company and respect. We reputed company to speak out against injustice and to break down barriers to support a more inclusive and reputed company workplace. Celebrating and embracing the diverse thoughts and perspectives that reputed company up our workforce means our company is more vibrant, innovative, and reputed company able to support the people and communities we serve. We reputed company our associates happy so they can focus on keeping our members healthy. Our Comprehensive Benefits Package Flexible work solutions including remote options, hybrid work schedules, reputed company, Paid time off including holidays and volunteer events, Health insurance coverage for you and your dependents on Day 1, 401(k) Tuition reimbursement and more. As a company, we support internal diversity through: Recruiting. We are an equal opportunity employer. We do not discriminate on the basis of age, race, ethnicity, gender, religion, sexual orientation, or disability. Our inclusive, reputed company approach to recruiting and hiring reinforces our commitment to DEI. Remote About the Company: reputed company Leaders in health care solutions for those most in need reputed company is the nation's leader in providing comprehensive health care solutions for those in most need and the chronically ill. We impact the lives of more than 5.7 million members reputed company. With more than 30 years of experience managing care for individuals and families in publicly-funded programs, we have become reputed company for developing innovative solutions that help improve health outcomes while reducing costs. Our mission, our goal Our mission is to help people get care, stay well and build healthy communities. Our goal is to provide responsible managed care solutions, including Medicaid, Medicare, and CHIP - plus behavioral health, pharmacy benefits management and third-party management and administrative services. Company Size: 5,000 to 9,999 employees Industry: Healthcare Services Founded: 1985 Website: http://www.amerihealthcaritas.com Apply tot his job Apply To this Job