Address
Form of workExempt or Non-ExemptExempt
Job Summary
Pay Range: $51,124 - $74,293
Note: Individuals typically begin between the minimum to middle of the pay range
Responsible for the intake, preliminary review and documentation of Fraud, Waste and Abuse (FWA) allegations referred to the Special Investigations Unit (SIU). Provides recommendations to close inquiries or open investigative cases for FWA incidents. Resolves FWA investigative cases via in-depth research and analysis through the recovery of healthcare dollars and allocation back to applicable entities. Manages regulatory notices, case summaries and coordinates with external entities, including but not limited to federal, state and law enforcement. Support on-site provider audits for the purposes of FWA investigations and internal audits as applicable.
Minimum Qualifications
- Bachelor's degree and one year of related work experience; or equivalent combination of education and related work experience.
- Fundamental knowledge/awareness of Fraud, Waste and Abuse.
- Strong oral and written communication skills.
- Basic working knowledge of Microsoft Word, Excel, and PowerPoint.
- Intermediate working knowledge of Microsoft Outlook.
Duties and Responsibilities
- SIU case investigation management and resolution:
- Manage FWA case investigations, collaborate with federal, state and law enforcement entities, and provide applicable notifications as required.
- Maintain extensive documentation and evidence for SIU cases.
- Recommend and implement preventive measures to combat FWA. schemes including, but not limited to provider education, policies, claims edits and payment suspensions.
- Manage the recovery, allocation and documentation of health plan funds resulting from FWA findings.
- SIU allegation intake and management:
- Manage the intake, documentation and resolution of FWA referrals to SIU.
- Coordinate with internal and external partners on FWA allegations.
- Assess needs, make recommendations and complete timely reviews in accordance with all regulatory requirements.
- Support SIU Operations:
- Create and maintain internal policies and procedures, workflows and presentations and present as needed to internal and external entities.
- Support regulatory audits and RFIs from law enforcement and federal and state entities.
- Represent SIU at cross functional workgroups and meetings and present case recommendations to other applicable business areas including, but not limited to Legal, Medical Management, Provider Operations and Claims Administration.
- Perform all other miscellaneous responsibilities and duties as assigned or directed.
