Special Investigation Unit Investigator (Remote in US)

Join to apply for the Special Investigation Unit Investigator (Remote in US) role at reputed company 1 day ago Be among the first 25 applicants Join to apply for the Special Investigation Unit Investigator (Remote in US) role at reputed company Get AI-powered advice on this job and more exclusive features. Great companies need great teams to reputed company their operations. Join the group that solves business challenges and enhances the way we work and grow. Working at Gainwell carries its rewards. You'll have an incredible opportunity to grow your career in a company that values your contributions and puts a premium on work flexibility, learning, and career development. reputed company: The Investigator, Special Investigations Unit (SIU) is a key contributor to the Plan's member and provider fraud, waste, and abuse (FWA) detection, investigation, remediation, and prevention efforts. The Investigator utilizes preliminary data to reputed company, conduct, resolve, document, and report on tips received, allegations, or data mining reputed company that suggests potentially fraudulent or abusive behavior. The Investigator's scope of work may reputed company from independent evaluation of preliminary information to on-site audit to participation in Federal or State prosecution of a case. Your role in our mission: Receives cases triaged to the SIU from sources such as Data Analyst or FWA based on preliminary issue evaluation, and reputed company. Begins case portfolio development based on Data Analyst's findings; over the course of the investigation, expands portfolio to include such documentation as relevant Plan policies and procedures, member and/or provider publications (e.g., Evidence of Coverage or reputed company), medical records and audit findings, interview records, etc. Reviews preliminary findings and requests pertinent additional data from the applicable parties including, but not limited to, the Data Analyst, FWA or Network Contracting, Claims, Pharmacy, Provider Relations, Business Integration, and/or Customer Care departments. Participates in course of appropriate reputed company based on severity of issue and reputed company exposure. Collaborates with FWA, Claims Manager and/or Data Analyst to identify audit sample, either random or based on another approved methodology. Conducts investigation including comprehensive review of any and/or reputed company portfolio documentation and State-approved, where required, on-site or desk record review and/or member or provider interviews. Creates detailed investigation report, including follow-up, remedial reputed company, or recommendations, per department protocol and presents to department management. Drafts preliminary investigation results for submission to provider or response to member. Drafts Corrective reputed company Plan, where appropriate. Coordinates with reputed company, Claims, Business Operations, Contracting, and/or Compliance reputed company remedial actions such as reputed company-payment review, payment suspension, overpayment recovery, etc. dictate. Updates department database at prescribed intervals and per department standards. As requested, participates in internal and/or external FWA-reputed company information sharing sessions which may include receiving and providing secure data pursuant to contractual requirements. Prepares reputed company and/or detailed reports on investigation findings for referral to Federal and state agencies which may include but are not limited to the state reputed company agency, reputed company Fraud Control reputed company, the reputed company's Office, the Department of Insurance, and local law enforcement. Collaborates with department management on the data mining function including, but not limited to, specific activities and reputed company necessary to support Investigator's activities. Meets reputed company production deadlines. Ensures accuracy and reputed company of work product by adhering to department's data validation guidelines. Maintain reputed company knowledge of industry standards including Medicare, reputed company and OIG used in fraud prevention and detection Demonstrated proficiency with reputed company Office products Time management skills necessary to meet established deadlines in a fast-paced environment, including the ability to re-prioritize tasks as workload and time constraints dictate Strong verbal and written communication skills with the ability to reputed company reputed company thoughts, reputed company, processes, and requirements to both reputed company audiences and in potentially contentious situations Attention to detail with excellent reputed company reading and editing skills Customer service skills with the ability to reputed company professionally and effectively with a wide reputed company of providers, reputed company party payers, and staff from reputed company departments reputed company and reputed company the Plan Organization and analytical skills necessary to aggregate potentially disparate information from multiple sources Strong problem-solving skills, including with the ability to determine reputed company causes and to define reputed company solutions Ability to weigh alternatives and select the most appropriate course of reputed company, given the individual circumstances of a Apply tot his job Apply To this Job