Job Description

Skills/Qualifications

• HS diploma or GED or Bachelor’s degree
• 8 years of experience in fraud, waste & abuse (FWA) investigations or special investigations unit (SIU) including 1 yr experience working with Medicaid
• Must hold one of the following certifications :
• CPA (Certified Public Accountant)
• CFE (Certified Fraud Examiner)
• AHFI (Accredited Health Care Fraud Investigator)
• INT – POPC Intermediate Peace Officer Proficiency Certificate

• Strong analytical and research skills.
• Proficient in researching information and identifying information resources.
• Exercises independent judgement and uses available resources and technology in developing evidence and supporting allegations of fraud, waste, and abuse.
• Knowledge of medical terminology and/or experience with CPT codes, and ICD-9, ICD-10 coding.
• Knowledge of suspected FWA trends and matters of interest to law enforcement and regulators.
• Strong communication and customer service skills.

Job Duties

• Coordinates with subcontractors on overseeing investigations of Fraud, Waste & Abuse (FWA).
• Manages a large fraud investigation caseload and investigates allegations relating to potential health care fraud perpetrated by Medicaid and commercial providers, vendors, and enrollees.
• Provides internal and external case updates on progression of investigations in coordination with SIU team members and other departments, including recommendations on further action and/or resolution, as needed.
• Continually interfaces with members, vendors, pharmacies, providers and other third parties via telephone, e-mail, and on-site visits as needed to identify, further, and conclude ongoing investigations.
• Implements processes and procedures to: prevent, detect, investigate and report FWA to appropriate regulatory agencies.
• Provides inter-departmental input regarding controls for preventing and monitoring FWA issues.
• Proactively identifies trends and aberrant activity to generate leads for FWA investigations.
• Performs special assignments related to FWA as assigned by the Director of Controls and Compliance.

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