Become a part of our caring community and help us put health first
 

The Senior Fraud and Waste Professional conducts investigations of allegations of fraudulent and abusive practices. The Senior Fraud and Waste Professional work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors.

The Senior Fraud and Waste Professional coordinates investigation with law enforcement authorities. Assembles evidence and documentation to support successful adjudication, where appropriate. Conducts on-site audits of provider records ensuring appropriateness of billing practices. Prepares complex investigative and audit reports. Begins to influence department’s strategy. Makes decisions on moderately complex to complex issues regarding technical approach for project components, and work is performed without direction. Exercises considerable latitude in determining objectives and approaches to assignments.

Use your skills to make an impact
 

Required Qualifications

Candidates must both be a South Carolina state resident AND have at least ONE of the following designations:

• Registered Nurse (RN)

• Actively certified by the American Academy of Professional Coders (AAPC) as a Certified Professional Coder (CPC)

• Actively professionally certified by AHIMA as a CCS-P

• Actively credentialed as a Certified Fraud Examiner (CFE) awarded by ACFE

• Currently designated as an Accredited Health Care Fraud Investigator (AHFI) granted by NHCAA

• Investigative/Law Enforcement background

• Other medical credentials such as Social Worker, Dental Hygienist, Pharmacist, etc

Preferred Qualifications

• Bachelor's degree

• At least 2 years of healthcare fraud investigations and auditing experience

• Knowledge of healthcare payment methodologies

• Strong organizational, interpersonal, and communication skills

• Inquisitive nature with ability to analyze data to metrics

• Computer literate (MS, Word, Excel, Access)

• Strong personal and professional ethics

• Must be passionate about contributing to an organization focused on continuously improving consumer experiences

• Graduate degree and/or certifications (MBA, J.D., MSN, Clinical Certifications, CPC, CCS, CFE, AHFI).

• Understanding of healthcare industry, claims processing and investigative process development.

• Experience in a corporate environment and understanding of business operations

Additional Information

Work at Home Requirements

•    WAH requirements: Must have the ability to provide a high speed DSL or cable modem for a home office. Associates or contractors who live and work from home in the state of California will be provided payment for their internet expense.
•    A minimum standard speed for optimal performance of 25x10 (25mpbs download x 10mpbs upload) is required.  
•    Satellite and Wireless Internet service is NOT allowed for this role.
•    A dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information

Interview Format 
As part of our hiring process, we will be using an exciting interviewing technology provided by Hire Vue/Modern Hire, a third-party vendor. This technology provides our team of recruiters and hiring managers an enhanced method for decision-making.

If you are selected to move forward from your application prescreen, you will receive correspondence inviting you to participate in a pre-recorded Voice Interview and/or an SMS Text Messaging interview.  If participating in a pre-recorded interview, you will respond to a set of interview questions via your phone. You should anticipate this interview to take approximately 10-15 minutes.

If participating in a SMS Text interview, you will be asked a series of questions to which you will be using your cell phone or computer to answer the questions provided.  Expect this type of interview to last anywhere from 5-10 minutes. Your recorded interview(s) via text and/or pre-recorded voice will be reviewed and you will subsequently be informed if you will be moving forward to next round of interviews.

Scheduled Weekly Hours

40

Pay Range

The compen