Fraud Investigator - Medicare

Peraton; United States; Teletrabalho; USD 70 000 - 100 000; Tempo integral

Resumo da oferta

SafeGuard Services, a Peraton subsidiary, seeks a Fraud Investigator for the SGS team to conduct high level investigations of medical provider activities, develop cases for action, and coordinate with law enforcement.

The role requires investigative experience, strong communication and organizational skills, and U.S. citizenship. Telework is available from Florida, South Carolina, or Virginia with expected travel ~25%.

Qualificações

• 5 years with BS/BA; or 9 years with a HS Diploma/equivalent
• Investigative experience
• Strong communication and organization skills
• Strong PC knowledge and skills
• Must be able to rent a car and have a valid driver's license
• U.S. citizenship required

Responsabilidades

• 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.
• Work with internal resources and external agencies to develop cases and corrective actions as well as respond to requests for data and support.
• Appear in court to testify about work findings.
• Research and draw conclusions, present issues with regulatory violations, and educate providers and stakeholders on safeguard matters.
• Organize case files, document steps taken, and prepare correspondence and referral summaries.
• Conduct site verifications to verify provider operational status; travel ~25% and telework from FL, SC or VA as applicable.

Conhecimentos

Investigative experience

Strong communication

Strong organizational skills

PC knowledge

U.S. citizenship

Formação académica

BS/BA or HS diploma/equivalent

Descrição da oferta de emprego

Basic Qualifications

• 5 years with BS/BA; or 9 years with a HS Diploma/equivalent
• Investigative experience
• Strong communication and organization skills
• Strong PC knowledge and skills
• Must be able to rent a car and have a valid driver's license
• 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.

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. This position may require the investigator to conduct field work on a monthly basis. Estimate 25% travel time.
• Telework available from Florida, South Carolina or Virginia.

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