Senior Investigator

Point32Health, Inc.; United States; Hybrid; USD 92,000 - 139,000; Full time

Job summary

Point32Health, Inc. seeks a Senior Investigator for its Special Investigations Unit (SIU) to lead complex provider investigations related to fraud, waste, and abuse.

The role involves coordinating with SIU peers to set priorities, develop strategies, and recommend measures to reduce losses while sharing expertise across Plan departments. The candidate should have a Bachelor's degree in a clinical or scientific field and 5–7 years of health insurance fraud investigations experience, with CPC

Qualifications

• Bachelor's degree in a clinical or scientific field, business, computer science, or criminal justice.
• CPC certification is required.
• CFE designation a plus.
• 5-7 years of health insurance fraud investigations experience.
• 3 years of audits/investigations preferred.

Responsibilities

• Lead complex investigations with internal and external research, data analyses, medical record reviews, and interviews with members, providers, and third parties.
• Apply laws, regulations, plan policies, contract provisions, coding rules, and industry standards to information gathered during investigations.
• Prepare reports of investigative findings and communicate results to providers.
• Collaborate with SIU management to educate providers, recover overpayments, prevent future loss, and monitor provider activity post-investigation.
• Identify root causes of fraud, waste, and abuse and recommend corrective actions.

Skills

clear documentation

collaborative

flexible

innovative

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.

Job Summary

The Senior Investigator is an essential team member of the 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 Senior 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. The Senior Investigator also serves as a resource to fellow SIU members and other Plan departments in the investigator's areas of investigative and clinical expertise.

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

• Lead complex investigations, involving internal and external research, detailed data analyses, review of medical records, and interviews of 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.
• Prepare reports of investigative findings and reporting investigative findings to providers.
• 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.
• Sharie expertise and promoting investigative best practices among SIU management and staff. 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 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, preferably in a clinical or scientific field, business, computer science, or criminal justice.

Preferred:

Experience

• Required (minimum): 5-7 years' related experience in health insurance fraud investigations.
• Preferred: 3 years' 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.
• 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

$92,414.18 -$138,621.26

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 reward