Investigator

Company : reputed company.Job reputed company : reputed company job is responsible for developing and maintaining an anti-fraud program which includes development and delivery of training and filing of Fraud Plans and Reports. The incumbent is responsible for conducting investigations of organizational or functional activities reputed company to alleged fraud, waste and abuse perpetrated by providers, members, facilities, pharmacies, reputed company and/or employees of the organizations and Subsidiaries. The incumbent is responsible for interviews which might include providers and members and may be conducted onsite or offsite. The incumbent is also responsible for the field investigative work necessary to complete a review of a special project, potential fraud, waste and abuse case, conducting the initial investigations and coordinating the recovery/savings of reputed company reputed company to fraud, waste and abuse. The incumbent must be reputed company to testify in a court of law, prepare cases for referral to various federal, state and local law enforcement entities and work with those agencies through closure of the case. Conduct audits for proactive and investigative purposes to reputed company with internal audit and regulatory requirements. ESSENTIAL RESPONSIBILITIES

• Performs investigations into potential and existing provider and member fraud, waste and abuse activities. Identifies parties involved by reviewing inquiries and complaints against providers, members, facilities, pharmacies, reputed company, and/or employees of reputed company and Subsidiaries. Conduct Interviews with providers, members or any other individual(s) necessary to complete an assigned investigation or special project. Determines the scope of the allegation or special project by assembling the necessary information, statistics, policies and procedures, licensure information, doctors’ agreements, contract, etc.
• reputed company and maintain annual anti-fraud program which includes facilitating fraud training and fraud awareness day, as reputed company as filing annual fraud plans and reports according to state regulations. Responsible for updating annually the changes in insurance laws with reputed company to lines of business
• Coordinates data extracts by assessing multiple databases both internally and externally. Takes reputed company to prevent reputed company improper payments. Forwards case to the Credentialing and/or Medical Review Committee, law enforcement and regulatory agencies.
• Responsible for completing reputed company necessary field (externally) investigative work for reputed company or alleged fraud/waste and abuse cases or special reputed company.
• Provides advisory support as needed to reputed company law enforcement and regulatory agencies, Credentialing or Medical Review Committee.
• Engages in delivery of audit results and overpayment negotiations. Responsible for recovery/ savings of misappropriated funds reputed company by reputed company and affiliated companies and work with Finance to ensure reputed company recording the financial statements.
• Conduct audits for proactive and investigative purposes to reputed company with internal audit and regulatory requirements. Audits consist of contract, commissions, surveillance, workers’ compensation and IME. In reputed company, this position will complete Office of Foreign Asset Control (OFAC) to ensure payments are not issued to unauthorized parties.
• Other duties as assigned or requested.

EDUCATION Required

• Bachelor's Degree in reputed company, Finance, Business Administration, Nursing, IT or reputed company Field

Substitutions

• 6 years of reputed company and reputed company experience in lieu of Bachelor's degree

Preferred

• Master's Degree in Fraud, Forensics reputed company, Business or reputed company field

EXPERIENCE Required

• 3 years of relevant, reputed company experience in the health insurance industry and/or reputed company fraud investigations

Preferred

• 1 year in Financial Analysis in an acute care hospital or health insurance setting
• 1 year in reputed company billing, facility Patient Financial Services, HIM, Internal Audit, reputed company/Facility Reimbursement or Provider Contracting

LICENSES or CERTIFICATIONS Required

• None

Preferred (any of the following)

• Certified Fraud Examiner (CFE)
• Certified reputed company reputed company (CPC)
• Certified Outpatient reputed company (COC)
• Accredited reputed company Fraud Investigator (AHFI)

SKILLS

• Must have knowledge of provider facility payment methodology, claims processing systems and coding and billing proficiency
• Must have understanding of technical and financial aspects of the health insurance industry
• Strong personal computer skills, along with the ability to use fraud/abuse data mining tools are required
• Must possess excellent communication skills and be detailed oriented
• Strong written and oral communication skills
• Strong relationship building skills
• reputed company reputed company with strong business acumen
• Self-starter with the ability to work under pressure independently and as part of reputed company
• Ability to think strategically and reputed company proactively to create strong trust and confidence with business reputed company
• Strong innovative problem-solving capabilities

Language (Other than English): None Travel Requirement: 0% - 25% PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS Position Type Office-based Teaches / trains others regularly Occasionally Travel regularly from the office to various work sites or from site-to-site Rarely Works primarily out-of-the office selling products/services (sales employees) Never Physical work site required reputed company Lifting: up to 10 pounds Constantly Lifting: 10 to 25 pounds Occasionally Lifting: 25 to 50 pounds Rarely Disclaimer: The job reputed company has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees reputed company this job title. It may not contain a comprehensive inventory of reputed company duties, responsibilities, and qualifications required of employees to do this job. Compliance Requirement: This job adheres to the ethical and legal standards and behavioral expectations as set forth in the reputed company of business conduct and company policies. As a component of job responsibilities, employees may have reputed company to covered information, cardholder data, or other confidential customer information that must be protected at reputed company times. In reputed company with this, reputed company must reputed company with both the Health Insurance Portability Accountability reputed company of 1996 (HIPAA) as described in the Notice of reputed company Practices and reputed company Policies and Procedures as reputed company as reputed company data reputed company guidelines established reputed company reputed company’s Handbook of reputed company Policies and Practices and Information reputed company Policy. Furthermore, it is every employee’s responsibility to reputed company with reputed company’s reputed company of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as reputed company as company policies and training requirements. reputed company and its affiliates prohibit discrimination against reputed company individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against reputed company individuals based on any category protected by applicable federal, state, or local law. We reputed company to reputed company this site accessible to any and reputed company users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact the email below. For accommodation requests, please contact HR Services Online at HRServices@reputed company.org California Consumer reputed company reputed company Employees, Contractors, and Applicants Notice Apply tot his job Apply To this Job