Investigator, Fraud, Waste & Abuse
Company: Commonwealth Care Alliance
Posted on: January 16, 2022
- Plan, organize, and execute investigations or audits utilizing
document review, witness interviews and data analysis to identify,
evaluate and measure potential healthcare fraud and abuse to
determine valid cases for appropriate action.
- Document and track activity in internal database, provide case
updates on progress of investigation, and coordinate with
management recommendations and further actions and/or
- Prepare detailed reports on investigative findings for internal
tracking, review and referral to Federal and State agencies as
- Utilize data mining and visualization programs to design
queries and analyze claims data to detect outliers or suspicious
patterns for further investigation.
- Conduct detailed research to identify and apply appropriate
regulatory, contractual and industry requirements to the different
benefits and products within investigations.
- Proactively seek out and develop leads, resources and
opportunities from a variety of sources, and develop and maintain
relationships with enterprise, industry, law enforcement and other
- Complete special projects and audits as required.
- Understand and adhere to HIPAA privacy
Bachelor's Degree or equivalent experience
- At least three (3) years of related investigative, claims,
compliance or analyst experience in healthcare, data reporting
and/or data analysis required. Internships will be considered.
- AHFI, CFE, CPC/medical coding, clinical background or formal
data analyst background preferred.
- Prior experience in health care compliance, regulation, SIU,
government agency or similar position related to data analysis or
an insurance-related field beneficial.
- Proficiency in Microsoft Office (Word, Excel, PowerPoint, and
- Demonstrated understanding of common fraud schemes and ability
to review and evaluate assigned referrals and apply appropriate
investigative strategies needed.
- Strong knowledge of standard industry coding guidelines such as
CPT, HCPCS, ICD 10 and NCCI.
- Ability to independently develop and present verbal and written
investigative and management reports.
- Knowledge of federal and state laws and regulations pertaining
to fraud, waste and abuse.
- Desire to work in a collaborative and fast-paced team
- Strong interpersonal, oral and written communication skills
including presenting to internal and external stakeholders.
- Ability to think creatively and approach this work to achieve
corrective actions and process improvements.
- Standard office equipmentEqual Opportunity Employer
Keywords: Commonwealth Care Alliance, Boston , Investigator, Fraud, Waste & Abuse, Other , Boston, Massachusetts
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