Medicare & Medicaid Program Integrity Investigator

SoftDev Incorporated; Pennsylvania; On-site; USD 70,000 - 100,000; Full time

Job summary

SoftDev Incorporated is seeking a Program Integrity Analyst to join our CMS-related team. The role involves high level investigations of medical service providers, case development for referrals, and collaboration with state and federal partners to address fraud, waste, and abuse.

The investigator will handle multiple caseloads, prepare reports, and maintain health privacy compliance while supporting data requests and corrective actions across multiple jurisdictions.

Qualifications

• US Citizen or Green Cardholder.
• BS 5-7 Years, MS 3-5, PhD 0-2
• Three to five years investigative experience preferred
• Strong investigative skills
• Strong communication and organization skills
• Experience in reviewing claims for technical requirements, performing medical review, and/or developing fraud cases
• Strong PC knowledge and skills
• Must pass a drug screening
• Must pass a criminal background check
• Must reside in any of the following states: Florida, Georgia, Alabama, Tennessee, South Carolina, North Carolina, Virginia, or West Virginia

Responsibilities

• This position will 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.
• Investigators may need to prepare complex investigative reports that apply regulations or rules to the programs affected by the behavior being investigated.
• Investigators will need to apply federal or state laws and maintain confidentiality of health privacy information.

Skills

Investigative skills

Data analysis

Communication skills

Team collaboration

Education

BS in a relevant field

MS preferred

PhD optional

Tools

MS Office

Data systems

Job description

SoftDev Incorporated is seeking a Program Integrity Analyst to join our CMS-related team. The role involves high level investigations of medical service providers, case development for referrals, and collaboration with state and federal partners to address fraud, waste, and abuse.

The investigator will handle multiple caseloads, prepare reports, and maintain health privacy compliance while supporting data requests and corrective actions across multiple jurisdictions.