Fraud Investigator (Medicaid/Medicare)

Responsibilities

SafeGuard Services (SGS), a subsidiary of Peraton, performs data analysis, investigation, and medical review to detect, prevent, deter, reduce, and make referrals to recover fraud, waste, and abuse.

 

The Fraud Investigator is expected to perform high level complex investigations of medical professional service providers and develop cases for future action, including referral to law enforcement, education, over payment recovery and other administrative actions.  Will work with internal resources and external agencies to develop cases and corrective actions as well as respond to requests for data and support.  

• An investigator uses good judgment and may work independently with minimum supervision and direction.
• The investigator also may work as part of a team as there may be times when the investigator needs to work with state and/or federal investigators and other personnel. 
• An investigator handles multiple caseload assignments concurrently; organizes and analyzes complex evidentiary patterns; interviews and obtains statements from witnesses and others.
• Investigators may also be required to complete complex investigative reports that apply regulations or rules to the program(s) affected by the behavior being investigated. There may also be times when the investigator will need to apply federal or state laws.
• Investigators are expected to research and understand the relevant offenses being investigated; conduct efficient and effective investigations concerning those alleged offenses and detect or verify suspected violations; obtain information and evidence by observation, record examination, and interview.
• Investigators then analyze the results of the investigation to ascertain if the allegations have been corroborated and work with others to determine the appropriate steps that need to be taken to address the issues.
• As part of an investigation, the investigator will need to prepare correspondence; be objective and accurate and communicate with others with tact.
• There may be times when investigators need to react to unplanned situations, be flexible in planning their activities and adopt effective courses of action.

• As investigators will be working with health privacy information, they also must maintain confidentiality and understand all the laws, rules and regulations concerning health privacy.
• Telework available from Maine, New Hampshire, Vermont, New York, Rhode Island, Connecticut, Massachusetts, Pennsylvania, Delaware, District of Columbia, New Jersey, Maryland, Northern Virginia.

 

Qualifications

Basic Qualifications:

• 2 years with BS/BA; 0 years with MS/MA; 6 years with HIgh School diploma
• 2 years investigative experience
• Knowledge of Medicare and/or Medicaid programs and the rules, regulations, policies and procedures
• Knowledge and experience in the healthcare industry.
• Strong investigative skills
• Strong communication and organization skills
• Strong PC knowledge and skills
• US citizenship is required

Preferred Qualifications:

• Strong background in investigations.
• Experience in reviewing claims for technical requirements, performing medical review, and/or developing fraud cases
• Knowledge of investigative practices regarding healthcare providers.
• Background in evaluating, reviewing and analyzing medical claims and records
• Ability to learn and operate a variety of data systems, equipment and tools used in investigations

Essential Functions:

• Ability to perform research and draw conclusions
• Ability to organize a case file, accurately and thoroughly document all steps taken
• Ability to present issues of concern, citing regulatory violations, alleging schemes or scams to defraud the Government
• Ability to compose correspondence, reports and referral summary letters
• Ability to communicate effectively, internally and externally
• Ability to interpret laws and regulations
• Ability to handle confidential material.
• Ability to manage and prioritize workload effectively so that customer metrics are met or exceeded.
• Ability to educate providers, provider associations, law enforcement, other contractors and beneficiary advocacy groups on program safeguard matters
• Ability to work independently and as a member of a team to deliver high quality work
• Ability to attend meetings, training, and conferences, overnight travel required.
• This position may require the incumbent to appear in court to testify about work findings.

 

Peraton Overview

Peraton is a n