Fraud Investigator - Medicare

Peraton; Northern (KY); Hybrid; USD 65,000 - 90,000; Full time

Job summary

SafeGuard Services, a subsidiary of Peraton, is seeking a Fraud Investigator to perform high-level investigations of medical professional service providers. You will develop cases for future action, coordinate with state and federal partners, and prepare investigative reports while handling health privacy considerations.

The role requires investigative experience, strong communication, and U.S. citizenship, with telework available from Georgia.

Qualifications

• 5 years with a Bachelor's or 9 Years with a HS Diploma/equivalent
• Investigative experience
• Strong investigative skills
• Strong communication and organization skills
• Strong PC knowledge and skills
• U.S. citizenship required

Responsibilities

• Perform high level complex investigations of medical professional service providers and develop cases for future action
• Coordinate with internal resources and external agencies to develop cases and corrective actions
• Prepare complex investigative reports applying relevant regulations
• Research and understand relevant offenses being investigated
• Obtain information and evidence by observation, record examination, and interview
• Communicate findings with tact and prepare correspondence and referral summaries
• Attend meetings, training, and conferences; overnight travel may be required
• Maintain confidentiality with health privacy laws and regulations

Skills

Investigative experience

Strong communication

Organization skills

Strong PC knowledge

U.S. citizenship

Education

Bachelor's degree

High School Diploma or equivalent

Job description

Basic Qualifications:

• 5 years with a Bachelors or 9 Years with a HS Diploma/equivalent
• Investigative experience
• Strong investigative skills
• 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 and/or Medicaid programs 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.

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.
• Telework available from: 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