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Investigator, Fraud, Waste & Abuse

Company: Commonwealth Care Alliance
Location: Boston
Posted on: January 16, 2022

Job Description:

  • 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 resolutions.
  • Prepare detailed reports on investigative findings for internal tracking, review and referral to Federal and State agencies as indicated.
  • 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 contacts.*
    • Complete special projects and audits as required.
    • Understand and adhere to HIPAA privacy requirements.Qualifications Required:
      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 Access) required.
      • 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 environment.
      • 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.
      • English
      • Standard office equipmentEqual Opportunity Employer Minorities/Women/Protected Veterans/Disabled

Keywords: Commonwealth Care Alliance, Boston , Investigator, Fraud, Waste & Abuse, Other , Boston, Massachusetts

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