Investigator I

THPP Tufts Health Public Plans Inc; Rhode Island; Hybrid; USD 67,000 - 100,000; Full time

Benefits offered by this job

Medical/dental/vision coverage

Retirement plans

Paid time off

Tuition program

Well-being benefits

Job summary

Point32Health is hiring an Investigator I for the Special Investigations Unit to lead provider investigations related to fraud, waste and abuse. You will apply laws, plan policies, review data and medical records, and prepare detailed reports.

Minimum bachelor’s degree and 1–3 years in health insurance fraud investigations; CPC or CFE preferred. You’ll work from home as needed, with occasional on-site meetings and a collaborative, fast-paced team environment.

Qualifications

• Certification and Licensure: CPC; CFE designation a plus.
• Education Required: Bachelor’s degree.
• Experience Required: 1-3 years’ related experience in health insurance fraud investigations.
• Skill Requirements: Clear, concise, well-organized documents; resilient, collaborative, flexible, innovative.

Responsibilities

• Lead straightforward and moderately complex investigations in fraud, waste and abuse.
• Conduct internal and external research, review data analyses, medical records, and interviews.
• Apply laws, plan policies, contract provisions, coding and coverage rules to investigation info.
• Complete detailed reports and notices for providers or entities.

Skills

CPC

CFE

Clear writing

Collaboration

Flexibility

Education

Bachelor's degree

Job description

Who We Are

Point32Health is a leading not-for-profit health and well-being organization dedicated to delivering high-quality, affordable healthcare. Serving nearly 2 million members, Point32Health builds on the legacy of Harvard Pilgrim Health Care and Tufts Health Plan to provide access to care and empower healthier lives for everyone. Our culture revolves around being a community of care and having shared values that guide our behaviors and decisions. We’ve had a long-standing commitment to inclusion and equal healthcare access and outcomes, regardless of background; it’s at the core of who we are. We value the rich mix of backgrounds, perspectives, and experiences of all of our colleagues, which helps us to provide service with empathy and better understand and meet the needs of the communities where we serve, live, and work. Learn more about who we are at Point32Health.

Job Summary

The Investigator I is an essential team member of the Special Investigation Init (SIU (Special Investigations Unit)) responsible for leading complex provider investigations related to fraud, waste, and abuse, and developing action plans to address the investigative findings and prevent future loss. The Investigator works closely with other members of the SIU to set investigative priorities, develop effective investigative strategies and techniques, and recommend measures to address new and evolving schemes.

Key Responsibilities/Duties – what you will be doing (top five):

• Lead straightforward and moderately complex investigations in specified areas of Fraud Waste and Abuse.
• Conduct internal and external research, review data analyses, review 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 (Fraud Waste and Abuse) concerns.
• Perform out-of-the-box thinking, collaborate with others, and make a difference every day.
• Other duties as assigned by the Manager or Director.

Qualifications – what you need to perform the job

• Certification and Licensure Certified Professional Coder (“CPC”); Certified Fraud Examiner (“CFE”) designation a plus.
• Education Required (minimum): Bachelor’s degree
• Preferred: Degree in a clinical or scientific field, business, accounting, computer science, or criminal justice
• Experience Required (minimum): 1-3 years’ related experience in health insurance fraud investigations.
• Preferred: Related experience in audits/investigations.
• Skill Requirements Ability to produce clear, concise, and well-organized documents.
• Resilient, collaborative, flexible, innovative.

Working Conditions and Additional Requirements (include special requirements, e.g., lifting, travel)

• Must be able to work under normal office conditions and work from home as required.
• May be required to attend meetings at other company locations or other external meetings.
• May be required to perform on-site evaluations of provider practice locations
• Work may require simultaneous use of a telephone/headset and PC/keyboard and sitting for extended durations.
• May be required to work additional hours beyond standard work schedule.

Disclaimer

The above statements are intended to describe the general nature and level of work being performed by employees assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of employees assigned to this position. Management retains the discretion to add to or change the duties of the position at any time.

Salary Range

$66,524.00 -$99,786.00

Compensation & Total Rewards Overview

The annual base salary range provided for this position represents a range of salaries for this role and similar roles across the organization. The actual salary for this position will be determined by several factors, including the scope and complexity of the role; the skills, education, training, credentials, and experience of the candidate; as well as internal equity. As part of our comprehensive total rewards program, colleagues are also eligible for variable pay. Eligibility for any bonus, commission, benefits, or any other form of compensation and benefits remains in the Company's sole discretion and may be modified at the Company’s sole discretion, consistent with the law. Point32Health offers their Colleagues a competitive and comprehensive total rewards package which currently includes:

• Medical, dental and vision coverage
• Retirement plans
• Paid time off
• Employer-paid life and disability insurance with additional buy-up coverage options
• Tuition program
• Well-being benefits
• Full suite of benefits to support career development, individual & family health, and financial health

For more details on our total rewards programs, visit https://www.point32health.org/careers/benefits/

We welcome all All applicants are welcome and will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.

Point32Health is a leading not-for-profit health and well-being organization dedicated to delivering high-quality, affordable healthcare. Serving nearly 2 million members, Point32Health builds on the legacy of Harvard Pilgrim Health Care and Tufts Health Plan to provide access to care and empower healthier lives for everyone. Our culture revolves around being a community of care and shared values that guide our behaviors and decisions. We’ve had a long-standing commitment to inclusion and equal healthcare access and outcomes, regardless of background; it’s at the core of who we are. We value the rich mix of backgrounds, perspectives, and experiences of all of our colleagues, which helps us to provide service with empathy and better understand and meet the needs of the communities where we serve, live, and work.