Fraud Investigatior - Medicare

Peraton; United States; Remote; USD 70.000 - 110.000; Vollzeit

Zusammenfassung

Peraton’s SafeGuard Services (SGS) is seeking a Fraud Investigator to conduct complex investigations into medical professional services, develop cases for potential referrals, and coordinate with law enforcement and other agencies. The role requires independent judgment, strict confidentiality, and the ability to handle multiple cases concurrently.

Responsibilities include preparing detailed reports, communicating findings with tact, and collaborating with state/federal partners.

Qualifikationen

• Minimum 5 years investigative experience with BS/BA or 9 years with HS diploma/equivalent.
• Strong communication and organizational skills are required.
• Solid PC knowledge and skills are required.
• U.S. citizenship is required.

Aufgaben

• Conduct high‑level, complex investigations of medical professional service providers and develop cases for action.
• Prepare and file complex investigative reports applying applicable regulations or rules.
• Collaborate with internal resources and external agencies; respond to data requests and referrals.
• Protect health privacy data and ensure confidentiality in all activities.
• Orchestrate case files; interview witnesses and obtain statements; testify when required.

Kenntnisse

Investigative experience

Communication skills

Organizational skills

PC knowledge

Ausbildung

5 years with BS/BA or 9 years with HS Diploma/equivalent

Jobbeschreibung

Responsibilities

SafeGuard Services (SGS), a subsidiary of Peraton, performs data analysis, investigation, and medical review to detect, prevent, deter, reduce, and make referrals to recover fraud, waste, and abuse.

We are looking to add a Fraud Investigator to our SGS team of talented professionals.

What you’ll do

The position is expected to perform high level complex investigations of medical professional service providers and develop cases for future action, including referral to law enforcement, education, over payment recovery and other administrative actions. Will work with internal resources and external agencies to develop cases and corrective actions as well as respond to requests for data and support.

An investigator uses good judgment and may work independently with minimum supervision and direction.

The investigator also may work as part of a team as there may be times when the investigator needs to work with state and/or federal investigators and other personnel.

An investigator handles multiple caseload assignments concurrently; organizes and analyzes complex evidentiary patterns; interviews and obtains statements from witnesses and others.

Investigators may also be required to complete complex investigative reports that apply regulations or rules to the program(s) affected by the behavior being investigated. There may also be times when the investigator will need to apply federal or state laws.

Investigators are expected to research and understand the relevant offenses being investigated; conduct efficient and effective investigations concerning those alleged offenses and detect or verify suspected violations; obtain information and evidence by observation, record examination, and interview.

Investigators then analyze the results of the investigation to ascertain if the allegations have been corroborated and work with others to determine the appropriate steps that need to be taken to address the issues.

As part of an investigation, the investigator will need to prepare correspondence; be objective and accurate and communicate with others with tact.

There may be times when investigators need to react to unplanned situations, be flexible in planning their activities and adopt effective courses of action.

As investigators will be working with health privacy information, they also must maintain confidentiality and understand all the laws, rules and regulations concerning health privacy.

Conduct site verifications in order to verify a provider's operational status.

Telework available from South Florida (preferred), and Georgia.

Essential Functions

• This position may require the incumbent to appear in court to testify about work findings.
• Ability to perform research and draw conclusions
• Ability to present issues of concern, citing regulatory violations, alleging schemes or scams to defraud the Government
• Ability to organize a case file, accurately and thoroughly document all steps taken
• Ability to compose correspondence, reports and referral summary letters
• Ability to educate providers, provider associations, law enforcement, other contractors and beneficiary advocacy groups on program safeguard matters
• Ability to communicate effectively, internally and externally
• Ability to interpret laws and regulations
• Ability to handle confidential material.
• Ability to report work activity on a timely basis.
• Ability to work independently and as a member of a team to deliver high quality work
• Ability to attend meetings, training, and conferences, overnight travel required

Qualifications

Basic Qualifications

• 5 years with BS/BA or 9 years with a HS Diploma/equivalent
• Solid Investigative experience
• Strong communication and organization skills
• Strong PC knowledge and skills
• U.S. citizenship required

Desirable Qualifications

• Strong background in investigations.
• Experience in reviewing claims for technical requirements, performing medical review, and/or developing fraud cases
• Knowledge of investigative practices regarding healthcare providers.
• Knowledge of Medicare program and the rules, regulations, policies and procedures
• Background in evaluating, reviewing and analyzing medical claims and records
• Ability to learn and operate a variety of data systems, equipment and tools used in investigations.

Peraton Overview

Peraton is a next-generation national security company that drives missions of consequence spanning the globe and extending to the farthest reaches of the galaxy. As the world's leading mission capability integrator and transformative enterprise IT provider, we deliver trusted, highly differentiated solutions and technologies to protect our nation and allies. Peraton operates at the critical nexus between traditional and nontraditional threats across all domains: land, sea, space, air, and cyberspace. The company serves as a valued partner to essential government agencies and supports every branch of the U.S. armed forces. Each day, our employees do the can't be