Seeking a full-time, remote, Medicare/Medicaid Fraud Investigator with experience in analyzing/interpreting data, understanding medical codes and services, and research/writing skills. The position requires proficiency in Microsoft Excel and Word. The ability to think outside the box and an inquisitive nature are a plus.
Summary Description
Perform evaluation and development of complaints to determine if referral as an investigation is warranted.
Accountabilities
Conduct independent reviews resulting from the discovery of situations that potentially involve fraud or abuse.
Utilize basic data analysis techniques to detect aberrancies in Medicare claims data, and proactively seeks out and develops leads received from a variety of sources (e.g., CMS, OIG, 1-800-MEDICARE, and fraud alerts)
Review information contained in standard claims processing system files (e.g., claims history, provider files) to determine provider billing patterns and to detect potential fraudulent or abusive billing practices or vulnerabilities in Medicare policies and initiates appropriate action
Make potential fraud determinations by utilizing a variety of sources such as internal guidelines, Medicare provider manuals, Medicare regulations, and the Social Security Act
Compile and maintain documentation and information related to investigations, cases, and/or leads
Participate in onsite audits in conjunction with investigation development
Develop and prepare potential Fraud Alerts and Program Vulnerabilities for submission to CMS; share information on current fraud investigations with other Medicare contractors, law enforcement, and other applicable stakeholders
Perform other duties as assigned by PI Supervisor or PI Manager that contribute to task order goals and objectives
Qualifications
Education (general level if required) or specific courses At a minimum, a high school diploma, with preference given to those candidates who have successfully completed college or technical degree programs related to the position (e.g., criminal justice, statistics, data analysis, etc.)
Preference will also be given to those individuals that have attained the Certified Fraud Examiners (CFE) designation
Skills, Knowledge
Abilities (SKA) Excellent oral, written and verbal skills
Ability to work independently with minimal supervision
Knowledge of statistics, data analysis techniques, and PC skills are preferred
Experience (If needed, describe kind & amount) At least 1 year of experience in program integrity investigation/detection or a related field that demonstrates expertise in reviewing, analyzing/developing information, and making appropriate decisions.