Special Investigations Unit Investigator

Job Description

Job Description

Hybrid-Sunrise, Florida

Experience Conducting Comprehensive Health Care Fraud, Waste, and Abuse (FWA) Investigations

POSITION SUMMARY :

The Special Investigations Unit Investigator is responsible for the investigation of potential fraud, waste, and abuse cases involving health plan providers and members. The Special Investigations Unit Investigator responsibilities include but are not limited to case management, research, investigation, documentation, and overpayment recovery.

ESSENTIAL DUTIES AND RESPONSIBILITIES :

• Accountable for managing a caseload of referrals and investigations involving potential member and / or provider fraud, waste, and abuse.
• Documents all appropriate case activity in case tracking system.
• Ensures compliance with all state and federal requirements related to FWA and FWA investigations.
• Performs data-mining activities to identify potential cases for investigation.
• Analyzes data as part of the investigative process.
• Performs research to analyze aberrant claims billing and practice patterns.
• Investigates and documents all fraud, waste, and abuse referrals and cases with a focus on thoroughness and attention to detail, quality, timeliness, and cost control. Testifies on investigations documented, as needed.
• Conducts comprehensive interviews with providers, members, and witnesses to obtain information which would be considered admissible under generally accepted criminal and civil rules of evidence.
• Conducts investigative steps out in the field throughout the service area as needed.
• Prepares and submits investigative reports covering all phases of the investigation.
• Works collaboratively with all SIU team members on aspects of the case.

This job description in no way states or implies that these are the only duties performed by the employee occupying this position. Employees will be required to perform any other job-related duties assigned by their supervisor or management.

QUALIFICATIONS :

SKILLS AND ABILITIES :

Work Schedule :

Community Care Plan is currently following a hybrid work schedule. The company reserves the right to change the work schedules based on the company needs.

PHYSICAL DEMANDS :

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to sit, use hands, reach with hands and arms, and talk or hear. The employee is frequently required to stand, walk, and sit. The employee is occasionally required to stoop, kneel, crouch or crawl. The employee may occasionally lift and / or move up to 15 pounds.

We are an equal opportunity employer who recruits, employs, trains, compensates and promotes regardless of age, color, disability, ethnicity, family or marital status, gender identity or expression, language, national origin, physical and mental ability, political affiliation, race, religion, sexual orientation, socio-economic status, veteran status, and other characteristics that make our employees unique. We are committed to fostering, cultivating and preserving a culture of diversity, equity and inclusion.

WORK ENVIRONMENT :

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of the job. The environment includes work inside / outside the office, travel to other offices, as well as domestic, travel. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The noise level in the work environment is usually moderate.