Special Investigations Unit Investigator II - III

Receives, analyzes and coordinates fraud and abuse complaints from internal sources (customer services, claims processing, underwriting, professional affairs) and external sources (members, providers, state and federal regulatory agencies, law enforcement), then conducts and coordinates moderately complex investigations with expertise across various case types, participating in post-audit exit interviews where appropriate. Provides accurate accounting of recovered funds from audit activities, criminal or civil convictions and settlements, demonstrating continuing success in settlement, recovery and collection activities related to fraudulent activity. Maintains continuing education through anti-fraud and legal issue seminars, holds at least one professional credential (CPC, CPC-H or CPC-P), reviews pertinent articles and regulatory requirements, and provides post-audit education to providers to correct discrepancies, and trains new Investigators and other Cambia employees in detection of abusive or fraudulent billing practices. Assists with maintenance of audit and investigation files, formulation of company policies addressing loss exposures and solutions, and maintains extensive contact with the provider community in both educational and potentially confrontational or adversarial investigative roles. Issues audit findings and prepayment claim determinations, including maintaining clear documentation of the basis of findings and determinations, and maintaining the required professional judgment to support and deliver them independently. Represents company at external and internal meetings dealing with fraud and abuse issues and litigation proceedings, testifies in court as required, and develops professional working relationships with various associations and agencies for detection of local and national fraud and abuse schemes. Conducts witness and target interviews, identifying and analyzing evidence, examining records to verify document authenticity, preparing and evaluating investigation reports, providing information for affidavit preparation, and maintaining communications with law enforcement and regulatory agencies to present case findings for further investigation, prosecution or administrative remedies. Requirements Bachelor's Degree, Program Certification (i.e. Fraud Examiner or Criminal Justice), or successful completion of law enforcement academy, with two years of job related experience or equivalent combination of education and work related experience. Certified Professional Coder (CPC) certification preferred. Experience with CMS and HHS-OIG/FBI or similar agencies preferred. Current RN or LPN licensure preferred. Extensive knowledge of medical procedures, terminology, and investigations, with experience in third party payer or independent health services contracting desired, along with investigative skills and exposure to the criminal justice system. Proficient with Microsoft Office software programs and demonstrated ability to handle confidential information, multiple tasks, and work independently with minimal supervision while functioning within corporate structure. Strong analytical, organizational and problem-solving abilities with demonstrated maturity, tact and composure in stressful or confrontational situations. Knowledge of state codes and regulations pertaining to health care and insurance industries, including legal terminology and procedures. Must have personal, reliable transportation, valid driver's license and proof of automobile insurance for on-site audits and investigations, with ability to work flexible schedules to accommodate investigation needs. Experience with AI tools and technologies to enhance productivity and decision-making in professional settings highly desired. Core Competencies Demonstrates expertise in fraud investigation and analysis, with strong knowledge of medical procedures and terminology, as well as proficiency in regulatory compliance and documentation. Capable of conducting interviews, maintaining professional relationships, and providing training on fraud detection and prevention. Highest-signal resume keywords Fraud Investigation Certified Professional Coder (CPC) Analytical Skills Knowledge of State Codes and Regulations Experience with CMS and HHS-OIG/FBI ATS Optimization Keywords Hard Skills Fraud Analysis Investigative Skills Medical Terminology Documentation Maintenance Audit Findings Issuance Soft Skills Organizational Abilities Problem-Solving Skills Tact and Composure Communication Skills Certifications & Qualifications Certified Professional Coder (CPC) Fraud Examiner Certification RN or LPN Licensure Industry Keywords Health Care Insurance Industry Criminal Justice System Regulatory Compliance Third Party Payer Contracting Tools & Technologies Microsoft Office AI Tools and Technologies #J-18808-Ljbffr Jobtailor