Senior Investigator

Responsibilities Conducts investigations into allegations of fraud, waste, or abuse, including preliminary assessments and full end-to-end case work. Reviews and analyzes medical records, claims data, enrollment data, and other documentation to evaluate potential FWA. Performs coding, billing, reimbursement, and medical necessity assessments based on CPT, HCPCS, ICD-9/10, DRG, and related coding guidelines. Uses advanced data mining techniques to identify aberrant billing patterns, outliers, and other indicators of fraudulent activity. Produces reliable, accurate and timely written investigative reports for internal and/external review detailing investigation findings, based on industry standard(s) and/or internal policy and procedure. Recommends possible interventions for loss control and risk avoidance based on the outcome of the investigation. Coordinates with various internal customers to gather documentation pertinent to investigations. Incorporates communication skills to work with physicians, other health professionals, attorneys as well as external regulatory agencies and law enforcement personnel. Communicate effectively and collaboratively with internal staff, leadership and external customers in a professional manner. Conducts settlement negotiations with providers and/or attorneys. Maintain the confidentiality required of the organization and the department. Follow all Health Insurance Portability and Accountability Act (HIPAA) and Personal Health Information (PHI) requirements and regulations. Qualifications Bachelor’s degree in business, criminal justice or related field. Certified Professional Coder (CPC), Accredited Healthcare Fraud Investigator (AFHI), Certified Insurance Fraud Investigator (CIFI), and/or Certified Economic Crime Forensic Examiner (CECFE) preferred (but not required). Minimum three (3) years’ experience with medical coding and medical record review performed required. Minimum three (3) years’ experience in healthcare industry within a Special Investigation Unit (SIU) or equivalent governmental agency responsible for investigating healthcare fraud required. Knowledge of medical coding and medical terminology. Experience using STARSSolutions or other healthcare FWA case management and detection software preferred (but not required). Proven track record in conducting investigations and/or the identification and pursuit of the recovery of overpayments. Excellent report writing skills. Knowledge of claims processing, reimbursement procedures, and a solid understanding of fraud detection and prevention practices. Knowledge of data analysis of claims and documenting findings on spreadsheets. Proficiency in Microsoft Office/Suite applications (Excel, Word, PowerPoint, Outlook, etc.). Excellent interpersonal and communication skills – oral, written and listening. #J-18808-Ljbffr