Fraud Investigator - Special Investigations Unit

The Investigator is an essential team member of the Special Investigation Unit (SIU) responsible for leading complex provider investigations related to fraud, waste, and abuse, and developing action plans to address the investigative findings and prevent future loss. The Investigator works closely with other members of the SIU to set investigative priorities, develop effective investigative strategies and techniques, and recommend measures to address new and evolving schemes.

Key Responsibilities/Duties – what you will be doing

• Lead complex investigations, involving internal and external research, detailed data analyses, review of medical records, and interviews of members, providers, and other third parties.
• Apply laws, regulations, plan policies and guidelines, contract provisions, coding rules, coverage rules, and industry standards to information gathered during the investigation.
• Prepare reports of investigative findings and reporting investigative findings to providers.
• Work with SIU management to educate providers, recover overpayments, take action to prevent future loss, and monitor provider activity post-investigation
• Identify root causes of fraud, waste and abuse and recommending internal and external corrective actions to address these root causes.
• Recommend investigative priorities, strategies, and techniques.
• Work with the analytics and intake team to develop and refine data mining to address new and evolving schemes and
• Sharie expertise and promoting investigative best practices among SIU management and staff. Educating and collaborate with various business units to raise awareness of potential FWA concerns.
• Perform out-of-the-box thinking, collaborate with others, and make a difference every day.

Qualifications – what you need to perform the job

• Bachelor's degree, preferably in a clinical or scientific field, business, accounting, computer science, or criminal justice.
• 1-3 years related experience in health insurance and/or fraud investigations.
• Certified Professional Coder (“CPC”); Certified Fraud Examiner (“CFE”) designation a plus.
• experience in audits/investigations (preferred).

SKILL REQUIREMENTS:

• Ability to produce clear, concise, and well-organized documents.
• Resilient, collaborative, flexible, innovative.

WORKING CONDITIONS AND ADDITIONAL REQUIREMENTS:

• Must be able to work under normal office conditions and work from home as required.
• May be required to attend meetings at other company locations or other external meetings.
• Work may require simultaneous use of a telephone/headset and PC/keyboard and sitting for extended durations.
• May be required to work additional hours beyond standard work schedule.

Commitment to Diversity, Equity & Inclusion

Point32Health is committed to making diversity, equity, and inclusion part of everything we do—from product design to the workforce driving that innovation. Our DEI strategy is deeply connected to our core values and will evolve as the changing nature of work shifts. Programming, events, and an inclusion infrastructure play a role in how we spread cultural awareness, train people leaders on engaging with their teams and provide parameters on how to recruit and retain talented and dynamic talent. We welcome all applicants and qualified individuals, who will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.

Who We Are

Point32Health is a leading health and wellbeing organization, delivering an ever-better personalized health care experience to everyone in our communities. At Point32Health, we are building on the quality, nonprofit heritage of our founding organizations, Tufts Health Plan and Harvard Pilgrim Health Care, where we leverage our experience and expertise to help people find their version of healthier living through a broad range of health plans and tools that make navigating health and wellbeing easier.

We enjoy the important work we do every day in service to our members, partners, colleagues and communities.

This job has been posted by Ignyte AI on behalf of Point32Health. Ignyte AI is committed to the fundamental principle of equal opportunity and equal treatment for every prospective and current employee. It is the policy of Ignyte AI not to discriminate based on race, color, national or ethnic origin, ancestry, age, religion, creed, disability, sex and gender, sexual orientation, gender identity and/or expression, military or veteran status, or any other characteristic protected under applicable federal, state or local law.

Req ID: R7846