Fraud, Waste & Abuse Investigator I — Remote

Point32Health, Inc.; United States; Hybrid; USD 67,000 - 100,000; Full time

Job summary

Point32Health, Inc. is seeking an Investigator I for its Special Investigations Unit to lead straightforward and moderately complex provider investigations related to fraud, waste, and abuse.

You will work with SIU peers to set priorities, develop strategies, and prepare detailed reports and findings for providers and other entities. The role requires 1–3 years of health insurance fraud investigation experience, a Bachelor's degree, and certification CPC and CFE is a plus.

Qualifications

• Bachelor's degree required.
• 1–3 years of health insurance fraud investigations required.
• CPC or CFE designation a plus.
• Strong written and verbal communication.
• Ability to work from home with occasional on-site meetings.

Responsibilities

• Lead straightforward and moderately complex investigations in specified areas of Fraud, Waste and Abuse.
• Conduct internal and external research, review data analyses, medical records, and interview members, providers, and other third parties.
• Apply laws, regulations, plan policies and guidelines, contract provisions, coding rules, coverage rules, and industry standards to information gathered during the investigation.
• Complete detailed reports of investigative activity and prepare summary findings notices for providers or other entities.
• As knowledge develops, expand investigative activities to include additional provider and service types.
• Work with SIU management to educate providers, recover overpayments, take action to prevent future loss, and monitor provider activity post-investigation.
• Identify root causes of fraud, waste and abuse and recommend internal and external corrective actions to address these root causes.
• Recommend investigative priorities, strategies, and techniques.
• Work with the analytics and intake team to develop and refine data mining to address new and evolving schemes and
• Share expertise and promote investigative best practices among SIU management and staff.
• Assist management in educating and collaborating with various business units to raise awareness of potential FWA concerns.
• Perform out-of-the-box thinking, collaborate with others, and make a difference every day.

Skills

Data analysis

Interviewing

Report writing

Regulations

Education

Bachelor's degree

Job description

Point32Health, Inc. is seeking an Investigator I for its Special Investigations Unit to lead straightforward and moderately complex provider investigations related to fraud, waste, and abuse.

You will work with SIU peers to set priorities, develop strategies, and prepare detailed reports and findings for providers and other entities. The role requires 1–3 years of health insurance fraud investigation experience, a Bachelor's degree, and certification CPC and CFE is a plus.