Investigator I

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

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.

We enjoy the important work we do every day in service to our members, partners, colleagues and communities. 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.

Job Description

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 r