SIU Investigator HFHP - Payment Integrity

POSITION SUMMARY

Responsible for conducting comprehensive investigations of reported, alleged, or suspected health care

fraud, waste and abuse (FWA).

PRIMARY ACCOUNTABILITIES

1. Conduct health plan related investigations, including reviews of medical records and data analysis, and make determinations as to whether the investigation and/or audit identified potential fraud, waste, or abuse, while focusing on thoroughness and attention to detail, quality, timeliness and cost control.
2. Conduct assessments of FWA allegations, complete investigations, including but not limited to witness interviews, background checks, claims data analytics to identify outlier billing behavior, contract and program regulatory research, provider and member education based on national or local guidelines, contractual, and/or regulatory requirements, while considering generally accepted criminal and civil rules of evidence.
3. Prepare and submit investigative reports covering all phases of the investigation, including but not limited to, post-audit investigative report and audit results letter to providers when overpayments are identified.
4. Prepare detailed investigation referrals to state and/or federal regulatory and/or law enforcement agencies when potential fraud, waste, or abuse is identified as required by regulatory and/or contract requirements.
5. Document appropriately all case related information in the case management system in an accurate manner.
6. Analyze, manipulate, validate, and summarize health care data with the purpose of understanding or making conclusions from the data for decision-making purposes, while using fraud detection software, corporate resources, departmental policies & procedures.
7. Actively participate in meetings and roundtables on FWA case development and referrals, attend appropriate education opportunities (NHCAA, Task Force Meetings, etc.) to keep apprised of developments in health care fraud.
8. Establish and maintain liaison with national trade organizations, other carriers’ audit anti-fraud professionals, public officials, law enforcement and others to obtain assistance in conducting investigations.
9. Maintain and manage an investigative caseload, determined by SIU leadership, while performing simultaneous duties.

MINIMUM QUALIFICATIONS

• Education: High School/GED
• Licensure: N/A
• Certification: None required
• Work Experience: Five years of applicable experience in healthcare investigations, fraud-related investigations, law enforcement or related experience.
• Work Experience in lieu of Education: N/A
• Knowledge/Skills/Abilities:

1. Knowledge of Commercial, Medicare, and pharmacy benefit laws and requirements; federal, state, civil and criminal statutes.
2. Proven investigatory skill; ability to organize, analyze, and effectively determine risk with corresponding solutions; ability to remain objective and separate facts from opinions.
3. Understanding of claim billing codes, medical terminology, anatomy, and health care delivery systems.
4. Understanding of datamining and use of data analytics to detect fraud, waste, and abuse.
5. Effective interpersonal skills and customer service focus; ability to interact with individuals at all levels.
6. Advanced skills in Microsoft Office (Word, Excel, PowerPoint, Outlook), SharePoint and Intra/Internet as well as proficiency with incorporating/merging documents from various applications.
7. Strong logical, analytical, critical thinking and problem-solving skills.

PREFERRED QUALIFICATIONS

• Education: Associate’s Degree in Business, Legal Studies, Criminology or Health related field
• Licensure: N/A
• Certification: Accredited Health Care Fraud Investigator (AHFI) or Certified Fraud Examiner (CFE)
• Work Experience: No additional Knowledge/Skills/Abilities: No additional
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• PHYSICAL REQUIREMENTS
• Majority of time involves sitting or standing; occasional walking, bending, and stooping.
• Long periods of computer time or at workstation.
• Light work that may include lifting or moving objects up to 20 pounds with or without assistance.
• May be exposed to inside environments with varied temperatures, air quality, lighting and/or low to moderate noise.
• Communicating with others to exchange information.
• Visual acuity and hand-eye coordination to perform tasks.
• Workspace may vary from open to confined.
• May require travel to various facilities within and beyond county perimeter; may require use of personal vehicle.

ABOUT HEALTH FIRST

At Health First, diversity and inclusion are essential for our continued growth and evolution. Working together, we strive to build and nurture a culture that recognizes, encourages, and respects the diverse voices of our associates. We know through experience that different ideas, perspectives, and backgrounds create a stronger and more collaborative work environment that delivers better results. As an organization, it fuels our innovation and connects us closer to our associates, customers, and the communities we serve.