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Special Investigations Unit Investigator
Special Investigations Unit Investigator Job
Full Job Title:
The Investigator conducts healthcare fraud and abuse investigations as a member of the Special Investigations unit within the Corporate Compliance department.
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.
Required A Bachelor's Degree in a related field or equivalent combination of education and 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
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
Preferred Intermediate Other Knowledge and understanding of claims processing systems and medical claims coding preferred
Preferred Intermediate Other Computer literate (MS Office, Excel, etc.)
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Last Updated On: 12/9/2015