Address
Form of workResponsibilities:
The Investigator is responsible for conducting comprehensive investigations of reported, alleged or suspected fraud involving the full range of products at the AmeriHealth Caritas Family of Companies (ACFC).
Major Accountabilities:
Education/ Experience:
The Investigator is responsible for conducting comprehensive investigations of reported, alleged or suspected fraud involving the full range of products at the AmeriHealth Caritas Family of Companies (ACFC).
Major Accountabilities:
- Ensures compliance with all requirements related to Special Investigation Units and fraud, waste and abuse investigations.
- Conducts highly complex, multi faceted investigations of potential fraud, waste and/or abuse with a focus on thoroughness and attention to detail, quality, timeliness and cost control.
- 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.
- Proactively performs research using the Internet, data analysis tools, etc., to analyze aberrant claims billing and practice patterns.
- Analyzes data as part of the investigative process using available fraud detection software and corporate resources.
- Represents ACFC in conducting settlement negotiations with providers, counsel and/or other associated parties.
- Prepares and submits investigative reports covering all phases of the investigation.
- Interprets and conveys highly technical information to others.
- Establishes and maintains liaison with public officials, law enforcement and others to obtain assistance in conducting investigations. Develops and leads collaborative relationships with internal and external constituents.
- Mentors and assists with skill development of new investigators.
Education/ Experience:
- Bachelor's Degree preferred or 3-5 years of relevant experience.
- Accredited Health Care Fraud Examiner (AHFI) and/or Certified Fraud Examiner (CFE) Required or eligible to obtain within 1 year of employment.
- Fraud Claim Law Specialist (FCLS) preferred.
- Valid driver's license required.
- Ability to work independently with minimal supervision, and manage a high volume of assignments.
- Strong verbal and written communication skills.
- High degree of integrity and confidentiality required handling information that is considered personal and confidential.
- Analytical skills and ability to make deductions; logical and sequential thinker.
