Auditor / Investigator I

Overview

Serves as an entry level professional who develops baseline plans for ensuring the integrity and accuracy of claims processes and protocols. Collects data for audits / investigations into claims, utilizing analytical skills and attention to detail, reviewing documentation, interviewing involved parties, and communicating with stakeholders to gather information for successful resolution and closure. Identifies opportunities to target fraud, waste, and abuse or discrepancies in claims submissions. Analyzes data to assess the validity of claims and provides accurate recommendations to management for claim resolution and closure. Documents and inputs all findings, preparing comprehensive reports that may be used for legal or audit purposes. Adheres to industry regulations and company policies for managerial follow-up.

Responsibilities

• Conducts routine and impartial audits / investigations into customer claims, ensuring accurate and fair assessments of claims validity.
• Provides customer service by addressing inquiries and concerns, and escalates audit / investigation as needed.
• Compiles detailed and organized records of audit / investigation findings, ensuring accuracy and compliance with legal and regulatory requirements.
• Applies functional knowledge to create and implement strategies to identify and prevent fraudulent activities, safeguarding the integrity of the claims process.
• Conducts interviews with relevant witnesses, claimants, and other stakeholders to gather information and perspectives on claims.
• Communicates with appropriate internal teams to ensure proper processing of audits / investigations, while adhering to legal and regulatory standards.
• Ensures that all audit and investigative documents and records are processed into the database in a timely and accurate manner.
• Communicates audit / investigation findings clearly and professionally to customers, claimants, and other stakeholders, managing expectations and providing updates.
• Supports management in regular audit and investigation proceedings, ensuring full compliance with applicable regional and federal standards, regulations, and protocols.

Qualifications

J-18808-Ljbffr