Health Plan Special Investigative Unit Investigator - Health Alliance Plan

GENERAL SUMMARY:Special Investigative Unit (SIU) Investigator responsible for investigating reports of non- compliance with corporate and regulatory policies, including reports of fraud, waste, or abuse. As a member of the SIU team, the investigator recommends methodologies which help prevent improper conduct by identifying, assessing, and correcting areas of noncompliance in risk areas in an effective manner. Utilize monitoring systems to track, remediate and create reports particularly from the data mining tool. Be responsible for all assigned investigations, follow-ups, and resolutions. Possess the judgement and discretion to handle cases that are sensitive and/or high profile, and the intellectual rigor and professional experience to work on complex cases that can be national in scope and involve intricate health care fraud schemes.PRINCIPLE DUTIES AND RESPONSIBILITIES:Independently analyze public and HAP internal data and information to develop preliminary assessment of facts to determine if full investigation is warranted. Develop investigative strategy and approach to complete investigation.Assembles evidence and documentation to support successful adjudication, where appropriate.Conducts on-site audits of provider records ensuring appropriateness of billing practices.Conduct interviews with providers, employees, members, and witnesses as part of the investigative process.Prepares complex investigative and audit reports with the ability to present investigation summaries that include metrics, trends, and schemes to various stakeholders, including enforcement agencies.Referral: The investigator must be able to craft a well-organized referral explaining the alleged fraud in a fraud referral to regulators.The Investigator coordinates investigation with law enforcement authorities and regulatory agencies.Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas.Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed.Follows established guidelines/procedures.Ensure that the compliance department meets the required OIG effective compliance program elements by promptly responding to identified issues and concerns within the organization.Work independently and manage a caseload which include investigations, identifying schemes, tracking, trending, and reporting instances of non-compliance.Respond to alleged violations of rules, regulations, policies, procedures, and Code of Conduct by evaluating or recommending the initiation of investigative procedures.Ensure policies and procedures are followed for the general operation of the compliance program and its related activities to prevent illegal, unethical, or improper conduct.Independently move an investigation to the next step in the investigative process with minimal assistance and errors. This includes from the opening to final disposition.Independently develop new cases based on proactive data mining efforts.Respond to a complaint, take statements, document effectively and identify any fraud, waste or abuse.Identify patterns and trends to generate new investigative leads.Collaborative Skills: Demonstrates strong teamwork and collaboration abilities, effectively working with other investigators to achieve common goals and take responsibility for team outcomes while contributing to the overall success of the team.Adaptability: Shows flexibility in adapting to different roles and responsibilities within the team, contributing to various aspects of investigations as needed.Demonstrated experience with Managed Care products such as Medicare, Medicaid, ACA, and commercial insurance.Develop and facilitate training regarding Fraud Waste and Abuse requirements, HFHS Non-retaliation policy, Code of Conduct, and government program requirements.Perform other related duties as assigned.EDUCATION/EXPERIENCE REQUIRED:Bachelor's Degree required.Master’s degree or Law degree preferred.Minimum of three (3) years of experience in healthcare, pharmacy technician, claims adjudication, medical billing/coding, nursing, or law enforcement.Minimum of two (2) years of experience conducting comprehensive investigations preferably with interacting with state, federal and local law enforcement agencies.Experience working for a health insurance payer.Moderate to expert proficiency with Excel, Word at a minimum, and an ability to learn other proprietary data software as determined by the SIU.Excellent organizational, prioritization and investigation skills.Experience working with RATSTATS or similar programs for sampling and extrapolation.Proficiency using excel including ability to analyze large data sets to identify trends, anomalies, and opportunities for improvement, using data visualization techniques to present findings effectively.Ability to use excel or other Microsoft software to automate repetitive processes and enhance existing workflows through advanced Excel features, including macros, pivot tables, complex formulas and power query.Experience with Microsoft Power BI and knowledge of sequel preferred.Excellent verbal, written and presentation skills.Ability to work with individuals of diverse backgrounds at various levels.Objective and creative analytical and auditing skills.Knowledge of various product lines in health care industry.Strong organizational, interpersonal, and communication skills.Inquisitive nature with ability to analyze data to metrics.Knowledge of healthcare payment methodologies.Knowledge and experience with FACETs or similar claim systems.Strong personal and professional ethics.CERTIFICATIONS/LICENSURES REQUIRED:Certification in CFE or AHFI required.CHC, CPC, CPHT, RN or Law enforcement preferred.Additional InformationOrganization: HAP (Health Alliance Plan)Department: Compliance & Legal AffairsShift: Day JobUnion Code: Not Applicable