Fraud Investigative Coordinator (SCA)

Peraton; Camp Hill (Cumberland County); Hybrid; USD 60,000 - 90,000; Full time

Job summary

Peraton's SafeGuard Services is seeking a Fraud Investigator Coordinator to support investigations in the Insurance/Healthcare space from a primarily telework setup, located near Camp Hill, PA. The role involves conducting interviews, researching systems, and coordinating with authorities to prevent fraud and abuse.

Excellent organization, strong documentation, and understanding of regulatory environments are essential.

Qualifications

• Proven ability to organize a case file and document steps clearly.
• Ability to interpret laws and regulations relevant to investigations.
• Willing to lift up to 50 lbs as part of site visits or file handling.

Responsibilities

• Investigate and take actions to resolve potential fraud or abuse in healthcare.
• Interview subjects as part of investigations and document findings.
• Collaborate with law enforcement and refer cases as needed.
• Develop case files and prepare appeals or referral summaries.
• Research appeals activity and support investigations with systems.
• Occasionally travel for meetings or training; telework majority.

Skills

Organizational skills

Computer proficiency

Research and reporting

Communication skills

Confidential information handling

Independent and team work

Willing to travel overnight

Education

BS 2-4 Years, MS 0-2 or HS 8-10

Tools

Microsoft Office Suite

Adobe

Job description

Basic Qualifications:

• BS 2-4 Years, MS 0-2 or HS 8-10
• Proven strong organizational skills
• Utilizea personal computer.
• Proficient in Microsoft Office Suite.
• Proficient with Adobe
• Able to lift up to 50 lbs.
• US. citizenship required

The most competitive candidates will have:

• Ability to search different systems to determine re-reviews of entities
• Knowledge of Medicare and/or Medicaid programs and the rules, regulations, policies and procedures
• Knowledge of Medicare Appeals process and different levels of Appeals
• Ability to learn and operate a variety of data systems, equipment and tools used in investigations

Essential Functions:

• Ability to perform research and draw conclusions
• Ability to organize a case file, accurately and thoroughly document all steps taken
• Ability to compose correspondence, reports and referral summary letters
• 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, may require overnight travel.

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 Coordinator to our SGS team of talented professionals.

What you'll do:

This position investigates and takes actions to resolve and/or prevent potential fraud or abuse in the Insurance/Healthcare space.Performs investigations to identify and resolve fraud or abuse. Interviews subjects as part of investigations. Collaborate with law enforcement by referring cases and providing subject matter expertise. Knowledge of claims/reimbursement practices and regulations. Understanding of regulatory environment. Knowledge of investigations processes, tools and practices. Case development and prosecution procedures. Additional activities may include:

• Receive requests from other entities and prepare appeals documents within specific time parameters
• Research and reporting appeals activity to support investigations
• Ability to perform appeals research using various systems
• Support with other clerical activities as needed
• The position is primarily telework, with the employee located near Camp Hill, PA.
• On-site presence in Camp Hill, PA office may be required occasionally.