Healthcare Fraud Investigator I

Point32Health, Inc.; Providence (RI); Hybrid; USD 67,000 - 100,000; Full time

Benefits offered by this job

Medical, dental and vision coverage

Retirement plans

Paid time off

Employer-paid life and disability

Tuition program

Well-being benefits

Job summary

Point32Health is seeking an Investigator I for its Special Investigations Unit in Providence, RI. You will lead straightforward and moderately complex investigations related to fraud, waste, and abuse, review data, medical records, and interview members and providers.

You will apply applicable laws, plan policies, coding and coverage rules, and prepare detailed investigation reports with findings notices. Collaboration with analytics and SIU leadership is essential.

Qualifications

• Bachelor’s degree required; clinical/science, business, accounting, computer science, or criminal justice preferred.
• 1–3 years’ related experience in health insurance fraud investigations.
• CPC and/or CFE are desirable.

Responsibilities

• Lead straightforward and moderately complex investigations in specified Fraud Waste and Abuse areas.
• 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.
• Identify root causes of fraud, waste and abuse and recommend corrective actions to address these root causes.

Skills

Certified Professional Coder

CFE designation

Education

Bachelor’s degree

Degree in clinical/scientific field, business, accounting, CS, or criminal justice

Job description

Point32Health is seeking an Investigator I for its Special Investigations Unit in Providence, RI. You will lead straightforward and moderately complex investigations related to fraud, waste, and abuse, review data, medical records, and interview members and providers.

You will apply applicable laws, plan policies, coding and coverage rules, and prepare detailed investigation reports with findings notices. Collaboration with analytics and SIU leadership is essential.