Job Description

Position Summary:

The Special Investigations Unit Investigator is responsible for the investigation of potential fraud, waste, and abuse cases involving health plan providers and members. The Special Investigations Unit Investigator responsibilities include but are not limited to case management, research, investigation, documentation, and overpayment recovery. FWA investigations experience in healthcare.

Essential Duties and Responsibilities:

1. Accountable for managing a caseload of referrals and investigations involving potential member and/or provider fraud, waste, and abuse.
2. Documents all appropriate case activity in case tracking system.
3. Ensures compliance with all state and federal requirements related to FWA and FWA investigations.
4. Performs data-mining activities to identify potential cases for investigation.
5. Analyzes data as part of the investigative process.
6. Performs research to analyze aberrant claims billing and practice patterns.
7. Investigates and documents all fraud, waste, and abuse referrals and cases with a focus on thoroughness and attention to detail, quality, timeliness, and cost control. Testifies on investigations documented, as needed.
8. Conducts comprehensive interviews with providers, members, and witnesses to obtain information which would be considered admissible under generally accepted criminal and civil rules of evidence.
9. Conducts investigative steps out in the field throughout the service area as needed.
10. Prepares and submits investigative reports covering all phases of the investigation.

This job description in no way states or implies that these are the only duties performed by the employee occupying this position. Employees will be required to perform any other job-related duties assigned by their supervisor or management.

SKILLS AND ABILITIES:

• Ability to communicate effectively, verbally and written.
• Ability to self-motivate.
• Strong time management skills
• Ability to prioritize and organize FWA program activities.
• Ability to meticulously document case actions and findings for regulatory reporting and any legal action, if applicable
• Ability to collaborate.
• Results oriented skills.

Work Schedule:

As a continued effort to provide a safe and productive work environment, Community Care Plan is currently following a hybrid work schedule. Staff are able to work from home 3 days a week and will report to the office 2 days a week. *****The company reserves the right to change the work schedules based on the company needs.

Physical Demands:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to sit, use hands, reach with hands and arms, and talk or hear. The employee is frequently required to stand, walk, and sit. The employee may occasionally be required to stoop, kneel, crouch or crawl. The employee may occasionally lift and/or move up to 15 pounds.

Work Environment:

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of the job. The environment includes work inside/outside the office, travel to other offices, as well as domestic travel. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The noise level in the work environment is usually moderate.

We are an equal opportunity employer who recruits, employs, trains, compensates and promotes regardless of age, color, disability, ethnicity, family or marital status, gender identity or expression, language, national origin, physical and mental ability, political affiliation, race, religion, sexual orientation, socio-economic status, veteran status, and other characteristics that make our employees unique. We are committed to fostering, cultivating, and preserving a culture of diversity, equity, and inclusion.

Qualifications

• Bachelor level education
• Minimum 3-5 years experience conducting comprehensive health care FWA investigations.
• Ability to work independently with minimal supervision and manage a high volume of assignments.
• High degree of integrity and confidentiality required handling information that is considered personal and confidential.
• Analytical skills and ability to make deductions, logical and sequential thinker.
• Strong verbal and written communication skills.
• Health care industry and/or Florida Medicaid knowledge required.
• Advanced knowledge and experience working on various approaches to health care fraud, waste, and abuse.
• Working knowledge of Microsoft applications, especially Excel, required.
• Knowledge of available resources (internal and external) to assist in investigations.
• Medical terminology knowledge and/or experience with CPT and ICD-10 coding preferred.
• Knowledge of suspected FWA trends, potential schemes, and matters of interest to law enforcement and regulators.
• Accredited Health Care Fraud Investigator (AHFI) and/or Certified Fraud Examiner (CFE) preferred.

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