Fraud Investigative Subject Matter Expert

Peraton; Huntsville (AL); Remote; USD 120,000 - 180,000; Full time

Job summary

SafeGuard Services (SGS), a Peraton subsidiary, seeks a Fraud Investigative Subject Matter Expert to lead investigative teams and provide advanced analysis in complex investigations spanning Medicare/Medicaid fraud. The role emphasizes mentoring staff, shaping investigative strategy, and coordinating with OIG, FBI/DOJ on high-profile matters.

The SME will testify when needed and guide processes to stop vulnerabilities, working across CMS and law enforcement partners.

Qualifications

• Minimum of 12 years with a Bachelor's degree or 16 years with a HS Diploma.
• Supervisory experience in the general area of program integrity investigations
• Experience working with CMS regulations and Medicare claims data require
• Strong knowledge of Medicare regulations, billing practices, and reimbursement methodologies
• Experience with fraud detection tools, claims analysis, and data mining technique Sunde
• Understanding of coding systems (ICD-10, CPT, HCPCS)
• Excellent analytical, investigative, and problem-solving skills
• Strong written and verbal communication abilities, including regulatory reporting
• Ability to manage sensitive and confidential healthcare information (HIPAA compliance)
• Must be a US Citizen
• Must be able to obtain and maintain the required agency clearance

Responsibilities

• Work with CMS, law enforcement and the Medicare Administrative Contractor throughout the life of the action
• Apply federal or state laws to investigations
• Work with health privacy information, maintain confidentiality and understand all the laws, rules and regulations concerning health privacy
• Present issues of concern, citing regulatory violations, alleging schemes or scams to defraud the Government
• Educate providers, provider associations, law enforcement, other contractors, and beneficiary advocacy groups on program safeguard matters
• The position is expected to provide subject matter expertise on investigative strategies for the most highly complex investigations of medical professional service providers
• Participate in the coordination of large-scale multi-subject fraud schemes/investigations. and oversee the development of cases for future action, including referral to law enforcement, education, over payment recovery and other administrative actions
• Participate in the coordination of projects with OIG, FBI/DOJ.
• Will work with internal resources and senior staff at external agencies to detect and deter emerging fraud schemes
• Provide strategic direction on stopping program vulnerabilities and deterring fraudulent providers in Medicare and Medicaid
• Coordinate major cases involving multiple internal and external resources
• Develop quality processes and training materials
• Telework available from anywhere in the United States.

Skills

CMS regulations

Medicare claims data analysis

Fraud detection tools

Data mining

ICD-10 CPT HCPCS coding

Analytical problem solving

Regulatory reporting

HIPAA compliance

Regulatory communication

Leadership

Public speaking/testimony

Education

Bachelor's degree

HS Diploma

Job description

Required Qualifications

• Minimum of 12 years with a Bachelors degree or 16 years with a HS Diploma.
• Supervisory experience in the general area of program integrity investigations
• Experience working with CMS regulations and Medicare claims data require
• Strong knowledge of Medicare regulations, billing practices, and reimbursement methodologies
• Experience with fraud detection tools, claims analysis, and data mining technique Sunde
• Understanding of coding systems (ICD-10, CPT, HCPCS)
• Excellent analytical, investigative, and problem-solving skills
• Strong written and verbal communication abilities, including regulatory reporting
• Ability to manage sensitive and confidential healthcare information (HIPAA compliance)
• Must be a US Citizen
• Must be able to obtain and maintain the required agency clearance

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 an Fraud Investigative Subject Matter Expert to our SGS team of talented professionals.

What You'll do

The Investigations Subject Matter Expert (SME) is a senior investigative lead responsible for leading and developing investigative professionals while serving in the role as a source of advanced expertise in complex investigative analysis.

A major responsibility of this position is to provide expert-level guidance and oversight in the evaluation, interpretation, and analysis of complex investigative information and evidence. The Investigations SME provides guidance in identifying, extrapolating, and evaluating relationships among pieces of evidence, information, and data; recognizing patterns and connections that may not be readily apparent; and identifying unforeseen links that may alter or expand the direction of an investigation. The position collaborates across teams in shaping investigative and analytical strategy, particularly for complex, sensitive, high-profile, or otherwise significant matters.

The position provides advanced coaching and mentorship to investigative staff, establishes direction for investigative and data review processes and procedures, and ensures the team is equipped to conduct thorough, accurate, defensible, and effective investigations. Applies advanced subject matter knowledge to manage staff activities in solving common and complex business/technical issues within established policies. Provides guidance on process improvements and recommends changes in alignment with business tactics and strategy for area of responsibility.

The Investigations SME will serve as an expert resource and witness in legal and administrative proceedings and may testify before grand juries, courts, administrative hearings, and other formal proceedings regarding investigative activities, evidence, analyses, findings, and results. The position may provide investigative expertise and testimony for high-profile, sensitive, or particularly complex cases.

Essential Functions

• Work with CMS, law enforcement and the Medicare Administrative Contractor throughout the life of the action
• Apply federal or state laws to investigations
• Work with health privacy information, maintain confidentiality and understand all the laws, rules and regulations concerning health privacy
• Present issues of concern, citing regulatory violations, alleging schemes or scams to defraud the Government
• Educate providers, provider associations, law enforcement, other contractors, and beneficiary advocacy groups on program safeguard matters
• The position is expected to provide subject matter expertise on investigative strategies for the most highly complex investigations of medical professional service providers.
• Participate in the coordination of large-scale multi-subject fraud schemes/investigations. and oversee the development of cases for future action, including referral to law enforcement, education, over payment recovery and other administrative actions.
• Participate in the coordination of projects with OIG, FBI/DOJ.
• Will work with internal resources and senior staff at external agencies to detect and deter emerging fraud schemes
• Provide strategic direction on stopping program vulnerabilities and deterring fraudulent providers in Medicare and Medicaid
• Coordinate major cases involving multiple internal and external resources
• Develop quality processes and training materials
• Telework available from anywhere in the United States.