SIU Investigator

The Investigator conducts healthcare fraud and abuse investigations as a member of the Special Investigations unit within the Corporate Compliance department.

Reports to: Manager, SIU & Compliance

Department: Compliance

Location: Tampa, FL

Essential Functions:

  • Manages large caseloads and investigates allegations and issues pertaining to potential health care fraud by providers or members.
  • Documents investigations, including preliminary and final case reports, for both internal tracking and regulatory reporting purposes.
  • Proactively identifies trends and aberrant activity to generate leads for fraud investigations and analyzes claims data to detect fraudulent activity.
  • Supports senior compliance staff and legal counsel in all phases of investigation and litigation.
  • Prepares cases for referral to government agency and law enforcement.
  • Develops and maintains strong working relationships with associates and regulators.
  • Testify in criminal and civil matters as needed.
  • Conducts special assignments as needed.
  • Trains associates regarding the activities of the Special Investigation Unit.
  • Perform other duties as assigned.
Additional Responsibilities:
    Candidate Education:
    • Required A Bachelor's Degree in a related field or equivalent combination of education and experience
    Candidate Experience:
    • Required 3 years of experience in Investigations, preferably health care fraud-related investigations or
    • Required 3 years of experience in healtcare involving investigatory-type analytic skills combined with a strong desire to develop additional investigatory skills.
    • Preferred 3 years of experience in Pharmacy Investigators - Pharmacy PBM and/or claims experience
    Candidate Skills:
    • Intermediate Other In-depth knowledge of government programs, the managed care industry, Medicare, Medicate laws and requirements, federal, state, civil and criminal statutes.
    • Intermediate Ability to work in a fast paced environment with changing priorities
    • Intermediate Demonstrated organizational skills
    • Intermediate Ability to multi-task
    • Intermediate Demonstrated written communication skills
    Licenses and Certifications:
    A license in one of the following is required:
    • Preferred Other Accredited Health Care Fraud Investigator (AHFI) or Certified Fraud Examiner (CFE)
    • Preferred Other Pharmacy Investigator - Certified Pharmacy Technician
    Technical Skills:
    • Preferred Intermediate Other Knowledge and understanding of claims processing systems and medical claims coding preferred
    • Preferred Intermediate Other Computer literate (MS Office, Excel, etc.)
    Languages:

      About us
      Headquartered in Tampa, Fla., WellCare Health Plans, Inc. (NYSE: WCG) focuses exclusively on providing government-sponsored managed care services through Medicaid, Medicare Advantage and Medicare Prescription Drug Plans to families, children, seniors and individuals with complex medical needs. WellCare is a Fortune 500 company, and in 2018, was recognized as a Fortune "World's Most Admired Company", ranking in the top five among the health insurance and managed care industry-a testament to the hard work and dedication of the company's nearly 9,000 associates who each day live WellCare's values and deliver on its mission to help its members live better, healthier lives. The company serves approximately 4.4 million members nationwide as of Dec. 31, 2017. For more information about WellCare, please visit the company's website at www.wellcare.com. EOE: All qualified applicants shall receive consideration for employment without regard to race, color, religion, creed, age, sex, pregnancy, veteran status, marital status, sexual orientation, gender identity or expression, national origin, ancestry, disability, genetic information, childbirth or related medical condition or other legally protected basis protected by applicable federal or state law except where a bona fide occupational qualification applies. Comprehensive Health Management, Inc. is an equal opportunity employer, M/F/D/V/SO.