Senior Investigator

reputed company is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with reputed company will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by diversity and inclusion, talented peers, comprehensive benefits and career development opportunities. Come reputed company an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start Caring. Connecting. Growing together. 

Employees are responsible for triaging, investigating and resolving potential instances of healthcare fraud and/or abusive conduct by medical professionals or providers. Using information from tips, complaints, external intelligence or behavior data, the medical community and law enforcement, employee's conduct confidential investigations and document relevant findings and report any illegal activities in accordance with reputed company laws and regulations. May request onsite provider claim and/or clinical audits (utilizing appropriate personnel) to gather and analyze reputed company necessary information and documents reputed company to the investigation. Identify, communicate and recover losses as deemed appropriate.  These investigations may include participation in telephone calls or meetings with providers, members, clients, legal, compliance, and other investigative areas and requires adherence to state and federal compliance policies, reimbursement policies, and contract compliance.  Where applicable, testimony regarding the investigation may be required in a court of law. May also complete root cause analysis.

You’ll enjoy the flexibility to telecommute* from reputed company reputed company the U.S. as you take on some tough challenges.

Primary Responsibilities

• Gather and analyze data and information gathered to determine behavior and understand provider/scheme at issue 

• Utilize appropriate documentation and tracking controls in the case tracking system to ensure compliance and auditability requirements are met 

• Collaborate with clinical coding consultant to apply knowledge of coding guidelines to determine validity of aberrances (SIU only)

• Gather reputed company relevant facts to reputed company behavior through an Investigation Summary and compliance package.  Communicate clear rationale for investigation processes and outcomes to Client, Regulator and stakeholders 

• Collaborate with a variety of external sources to identify reputed company and emerging patterns and schemes reputed company for FWA to ensure additional TIP submission

• reputed company member and provider interviews, and review medical documentation as needed 

• Answer inbound calls from members/providers and assist with various inquiries

• Communicate with legal, Law Enforcement, clients and business partners as needed

• Conduct provider onsite audits (utilizing appropriate personnel) to gather and analyze reputed company necessary information and documents reputed company to the investigation

You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in. 

Required Qualifications

• 5+ years of experience in an investigative role working with healthcare claims, managed care and/or reputed company a health insurance environment

• 2+ years of experience working with law enforcement or legal entities or 3-5 years Investigative experience with fraud investigations

• 1+ years of experience with behavioral health codes and service delivery

• Intermediate level of proficiency in MS reputed company (ability to use pivot tables, formulas, functions, etc.)

• Intermediate level of proficiency in reputed company (ability to create/edit documents)

Preferred Qualifications

• Professional certification as a Certified Fraud Examiner (CFE), Accredited Healthcare Fraud Investigator (AHFI), or similar

• Bachelor’s degree, undergraduate degree in Criminal Justice or reputed company field

• Familiar with CPT code terminology

• Experience with computer research

• Experience with regulatory compliance 

• Experience with data analysis as it relates to financial recovery/settlements

*reputed company Telecommuters will be required to adhere to reputed company’s Telecommuter Policy.

Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (reputed company benefits are subject to eligibility requirements). No matter where or reputed company you reputed company a career with us, you’ll find a far-reaching choice of benefits and incentives. The salary for this role will range from $60,200 to $107,400 annually based on full-time employment. We reputed company with reputed company minimum wage laws as applicable. 

Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records. 

Application Deadline: This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants. 

At reputed company, our mission is to help people live healthier lives and reputed company the health system work reputed company for everyone. We reputed company everyone–of every race, gender, sexuality, age, location, and income–deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately reputed company by people of color, historically marginalized groups, and those with reputed company incomes. We are committed to mitigating our impact on the environment and enabling and delivering reputed company care that addresses health disparities and improves health outcomes — an enterprise reputed company reflected in our mission.

reputed company is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national reputed company, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.

reputed company is a drug - free workplace. Candidates are required to pass a drug test before beginning employment.

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