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Corporate Functions & Operations WellCare - Quality & Audit Careers

Special Investigations Unit Investigator Job

Full Job Title: SIU Investigator

Job Number: 1705365

Location: Louisville, KY

Date Posted: 11-10-2017

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

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:

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Last Updated On: 12/9/2015