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The Senior Investigator investigates cases of health care fraud and abuse within the Special Investigations Unit (SIU). He or she will assume responsibility for higher profile and more complex cases and will also be expected to serve as a resource to more junior SIU staff.
Manages large caseloads and investigates allegations and complex 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 law enforcement officials for prosecution.
Develops and maintains strong working relationships with associates and regulators.
Testify in criminal and civil matters as needed.
Conduct special assignments as needed.
Trains associates regarding the activities of the Special Investigation Unit.
Provides training, mentors and oversight of junior staff on casework and other SIU activities.
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 required
Required 5 years of experience in Investigations and healthcare fraud-related investigations combined
Advanced Knowledge of community, state and federal laws and resources
Advanced Other In-depth knowledge of government programs, the managed care industry, federal, state, civil and criminal statutes, and Medicare & Medicaid laws and requirements.
Advanced Ability to multi-task
Advanced Demonstrated written communication skills
Advanced Demonstrated organizational skills
Advanced Ability to work in a fast paced environment with changing priorities
Intermediate Demonstrated leadership skills
Licenses and Certifications: A license in one of the following is required:
Preferred Other Accredited Healthcare Fraud Investigations (AHFI) or Certified Fraud Examiner (CFE)
Preferred Other Pharmacy Investigator - Certified Pharmacy Technician
Required Intermediate Other Knowledge and understanding of claims processing systems and medical claims coding preferred
Preferred Intermediate Other Computer literate (MS Office, Excel, etc.)