Lead Investigator – Validation, Fraud, Waste & Abuse

Job Description:

• Identify, investigate, analyze and evaluate instances of potential fraud, waste, and abuse
• Proactively monitor provider activity to identify patterns, anomalies, and emerging trends warranting further investigation
• Use data analytics, claims review, and industry intelligence to detect potential fraud, waste, abuse, or non-compliance
• Leverage claims data, dashboards, and predictive models to identify providers with atypical billing patterns or potential fraud, waste, and abuse
• Analyze investigation information and report findings and recommendations in written summaries and/or presentations
• Conduct investigation-related training
• Support legal proceedings as needed, including testifying in court or working with law enforcement personnel to prepare civil or criminal cases
• Maintain current knowledge of relevant laws, regulations and standards
• Participate in special projects as required
• Complete responsibilities outlined on the annual Performance Plan
• Complete special projects and other assigned duties

Requirements:

• Bachelor’s Degree in related discipline, or the equivalent combination of education, professional training, and work experience
• At least 2 years of related healthcare FWA investigative experience
• Experience in proactive data mining
• Experience in sampling and data extrapolation
• Advanced level skills in Excel required
• Preferred certifications: Accredited Healthcare Fraud Investigator (AHFI), Certified Fraud Specialist (CFS), or Certified Fraud Examiner (CFE)
• Prior use with RAT-STATS preferred
• Experience using Cotiviti FWA tools preferred: Sentinel, Commander, and/or Informant (Stars Solutions)
• Excellent verbal and written communication skills
• Strong listening and observation skills
• Attention to detail and high level of accuracy
• Effective organizational and prioritization skills with multi-tasking ability
• Must have a work location within the continental US
• Must provide a high-speed internet connection and a work environment free from distractions
• Must be able to provide a dedicated, secure work area
• Must be able to provide high-speed internet access/connectivity and office setup and maintenance
• Must be able to perform duties with or without reasonable accommodation

Benefits:

• Medical insurance
• Dental insurance
• Vision insurance
• Disability insurance
• Life insurance coverage
• 401(k) savings plans
• Paid family leave
• 9 paid holidays per year
• 17-27 days of Paid Time Off (PTO) per year, depending on specific level and length of service
• Remote at-home work arrangement
• Very limited travel
• High-speed internet and dedicated secure work area requirements supported as work setup provisions