Investigates and remediates compliance and sales & marketing related matters deemed to be of minimal to moderate complexity. Supports senior level investigators with complex investigations and assist with internal and external reporting.
REPORTS TO: Director of Compliance Investigations
Additional Responsibilities:Candidate Education:
- Ensures adherence to compliance with established standards, policies and procedures.
- Independently evaluates and assesses allegations to determine those criteria, including federal and state regulations, Centers for Medicare & Medicaid Services ("CMS") guidelines, and internal policies, procedures, and standards that are alleged to have been violated.
- Prepares and performs review of departmental and Company metrics including, but not limited to, Sales & Marketing activities, internal investigations.
- Conducts interviews with beneficiaries, sales agents, providers, associates, and/or downstream entities as required for investigatory purposes.
- Identifies risks, interprets investigation results, and recommends remedial actions to mitigate future potential risks.
- Prepares clear and concise draft investigative plans and reports.
- Supports the planning, development, and coordination of multiple projects, including prioritizing and managing through execution. Thoroughly documents and organizes case files, electronic and hard copy, relative to each investigation in accordance with Company / departmental policy and ensures remediation activities are tracked and implemented.
- Prepares and performs review of Company and departmental metrics including, but not limited to, Sales & Marketing activities, internal investigations.
- Performs other duties as assigned.
- Preferred - A Bachelor's Degree in a related field
- Required 2 years of experience in an investigator or loss prevention type role preferably within Healthcare or relevant industry
Licenses and Certifications:
- Intermediate Demonstrated organizational skills
- Intermediate Demonstrated written communication skills
- Intermediate Demonstrated interpersonal/verbal communication skills
- Intermediate Demonstrated problem solving skills
- Intermediate Ability to work within tight timeframes and meet strict deadlines
- Beginner Demonstrated analytical skills
- Beginner Other Basic understanding of statistics
- Intermediate Other Demonstrate knowledge of Medicare and/or Medicaid
A license in one of the following is required:
- Required Intermediate Microsoft Word
- Required Intermediate Microsoft Outlook
- Required Intermediate Microsoft Excel