Special Investigator

LOCATION : Remote must live in or / near Vaya’s catchment area. Must also reside in North Carolina or within 40 miles of the NC border.

GENERAL STATEMENT OF JOB

The Special Investigator works under the direct supervision of the Special Investigations Operations Manager. The Special Investigator is responsible for identification, investigation and prevention of healthcare fraud, waste and abuse within the Vaya Health Network of contracted providers.

The Special Investigator will develop investigative summary reports and make applicable referrals to the NC Division of Health Benefits, and recommendations as necessary to providers associated with investigation findings / outcomes.

ESSENTIAL JOB FUNCTIONS

Investigative Activities :

• Utilize established Vaya procedures to conduct inquiries and investigations into complaints, allegations, and referrals regarding suspected Fraud, Waste or Program Abuse
• Review healthcare claims to determine if provider payments were rendered in accordance with rules, regulations, service definition, service utilization, and contractual requirements
• Determine correct coding, billing, documentation, delivery of services and potential violations of federal and / or state regulation or Medicaid guidelines
• Perform reviews (desk, virtual, and / or on-site); interview providers, members, and stakeholders, and review medical records to verify compliance with program policies and / or standards of health care, appropriateness of services or medical necessity
• Prepare reports and exhibits from the findings of provider investigations and develop recommendations or intervention strategies to correct or prevent abusive practices, including proposals to recover inappropriately paid moneys or to suspend or terminate program participation.
• Refer suspected fraud cases to the DHB Office of Compliance and Program Integrity

Administrative Activities :

• Participate in both informal and formal appeal processes, defending their decisions before a Vaya reconsideration panel, hearing officers and / or administrative law judges
• Provide litigation testimony as applicable
• Work in conjunction with various regulatory bodies
• Propose new fraud prevention edits for automated claims / billing system when new fraudulent schemes are discovered

Support Activities :

Other duties including technical assistance and provider education may be assigned based upon need, area of expertise, special interests and availability of resources.

KNOWLEDGE, SKILL & ABILITIES :

• Knowledge of healthcare service definitions, service documentation, and service utilization requirements
• An intermediate level of knowledge of Local, State and Federal laws and regulations pertaining to insurance and / or healthcare services
• Possess comprehensive knowledge of fraud investigative procedures and judicial processes relating to fraud prosecutions
• Excellent decision-making abilities to determine the appropriate course of action during

investigations and subsequent follow-up

• Ability to prepare detailed and comprehensive reports, to present facts clearly, and to instruct others in new methods and procedures
• Present investigative findings with regulatory violations citations and ability to accurately describe scheme(s) to defraud Medicaid
• Intermediate or better proficiency with Microsoft Word, Microsoft Outlook, and Excel
• Ability to work autonomously, exercising sound judgment and problem resolution skills
• Ability to establish appropriate and respectful relationships / partnerships with persons with a wide range of ethnicities and abilities

QUALIFICATIONS & EDUCATION REQUIREMENTS

Associate degree in Compliance, analytics, government / public administration, auditing, security management or pre-law, psychology, social work, arts, science or a related human service field.

Bachelor’s degree preferred. Must have three (3) years of experience in compliance, healthcare, or fraud investigation unit.

Preferred Licensure / Certification :

Accredited Healthcare Fraud Investigator, Certified Fraud Examiner, or Certified Professional Coder preferred.

PHYSICAL REQUIREMENTS :

• Close visual acuity to perform activities such as preparation and analysis of documents; viewing a computer terminal; and extensive reading.
• Physical activity in this position includes crouching, reaching, walking, talking, hearing and repetitive motion of hands, wrists and fingers.
• Sedentary work with lifting requirements up to 10 pounds, sitting for extended periods of time.
• Mental concentration is required in all aspects of work.

RESIDENCY REQUIREMENT : This position is required to reside in North Carolina or within 40 miles of the North Carolina border.

SALARY : Depending on qualifications & experience of candidate. This position is exempt and is not eligible for overtime compensation.