SIU Fraud Investigator

Mass General Brigham Health Plan is an exciting place to be within the healthcare industry. As a member of Mass General Brigham, we are at the forefront of transformation with one of the world's leading integrated healthcare systems. Together, we are providing our members with innovative solutions centered on their health needs to expand access to seamless and affordable care and coverage. Our work centers on creating an exceptional member experience - a commitment that starts with our employees. Working with some of the most accomplished professionals in healthcare today, our employees have opportunities to learn and contribute expertise within a welcoming and supportive environment that embraces their unique and varied backgrounds, experiences, and skills. We are pleased to offer competitive salaries and a benefits package with flexible work options, career growth opportunities, and much more. Role Overview The role will be responsible for creating, refining, and performing various analytic reporting aimed at identifying potential fraudulent, wasteful, or abusive claim submissions. In addition to performing analytics, the Data Analyst will be required to conduct preliminary research of identified providers or members, including public records, contracts, and social media reviews. The analyst will be accountable for documenting analytical and research activities in concise reports or memoranda. Essential Functions Responsible for conducting confidential investigations of suspected fraud, waste & abuse (FWA) involving medical providers, plan members, or other entities or individuals. Investigative activities include, but are not limited to: data analysis, public records research, document review, and interviewing. Performs case research to include the review, interpretation, and application of payment policies, medical policies, provider manuals, benefits documents, national or local coverage determinations, and other applicable clinical practice parameters, regulations, or guidance pertaining to the submission of claims to health insurance plans. Obtains investigative evidence by requesting medical and administrative documents and by conducting interviews of providers, members, or other associated parties. Analyzes and interprets multiple sources of data, including health insurance claims, financial transaction information, contract configurations, and other materials. Is an expert report writer with the ability to create timely documentation, including investigative plans, case summaries, and interview reports. Stays up to date with industry trends, including those pertaining to prevailing fraud, waste & abuse schemes. Education Bachelor's Degree in Related Field of Study required; experience can be considered in lieu of a degree. Experience At least 5-7 years of experience conducting fraud, waste, and abuse investigations required. Knowledge, Skills, and Abilities Strong, demonstrated track record of the ability to execute on time, on budget, and on scope. Strong aptitude for technology-based solutions. Excellent leadership skills and leadership track record. Ability to translate and communicate complex topics in a variety of forums. Excellent interpersonal skills. Working Conditions This is a hybrid role that requires an on-site presence at the office in Assembly Row, Somerville roughly once per month. Mass General Brigham Health Plan Holding Company, Inc. is an Equal Opportunity Employer. By embracing diverse skills, perspectives and ideas, we choose to lead. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment. #J-18808-Ljbffr Mass General Brigham Health Plan