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In this role you will be part of the Program Integrity team within the Compliance Department responsible for identification, investigation and prevention of healthcare fraud, waste, and abuse. This includes meeting all regulatory and contractual requirements in relation to network provider fraud, waste, and abuse investigations and reporting for both government and commercial lines of business.

The Compliance Department plays a pivotal role in ensuring that Avēsis adheres to federal and state regulations, as well as internal policies. It is responsible for preventing, detecting, and correcting compliance risks that could impact the Avesis’ operational effectiveness as well as legal and reputational standing. The Compliance Department works to promote a culture of ethics, transparency, and accountability across the enterprise, making sure that all employees understand their responsibilities and the importance of adhering to legal, regulatory and compliance standards. Additionally, it provides ongoing training and resources to help staff stay informed about regulatory updates and best practices.

The Senior FWA Investigator will be part of the FWA team responsible for tracking and trending provider patterns through development of dashboards and claims data analyses to target provider outliers.    The senior investigator is responsible for conducting investigations as needed, which will include medical record reviews, as well as obtaining any other documentation relevant to an investigation, documenting findings, and reporting to appropriate health plan.  In addition, the senior investigator position will be responsible for maintenance and monitoring of provider disciplinary actions within the FWA department as a result of investigations.  The Senior FWA Investigator will assist in training new investigators as well as monitor client FWA activities for compliance.

Functional Competencies

• Investigate dental cases of fraud, waste, and abuse timely and accurately of dental and vision network providers
• Develop and deploy effective and efficient investigative tools and best practice strategies for investigative processes within the FWA department
• Maintain accurate, current and thorough case information in the FWA tracking system
• Collect and secure documentation in relation to all FWA investigations; prepare summaries of findings as well as summary reports of outcomes
• Prepare investigative/client presentations for FWAent to both internal and external parties
• Identify and refer instances of suspected dental or vision fraud as appropriate to the Health Plan
• Accurately track overpayment recoveries, document and work with collection agency to collect when necessary
• Collect, collate, analyze, and interpret data relating to fraud, waste, and abuse referrals
• Collect, collate, analyze, and interpret data relating to internal investigative activities
• Identify payment integrity/cost avoidance opportunities resulting from investigations
• Assist in development of standard operating procedures as needed within the FWA department
• Ensure compliance of applicable federal/state regulations and/or contractual obligations
• Report suspected fraud, waste, and abuse to appropriate federal or state government regulators; accurately fill out required reporting templates
• Comply with goals, policies, procedures, and strategic plans as delegated by leadership
• Collaborate with state/federal partners, at the discretion of leadership, to include attendance at workgroups or regulatory meetings

Core Competencies

• Understand the CPT and procedural coding for dental and vision claim submissions and the client policies/benefits related to those codes
• Be able to work independently through provider investigations and deploy effective and efficient investigative strategies for each investigation as well as
• Be able to collect and secure adequate documentation in relation to dental investigations and prepare summaries of findings
• Understand what constitutes suspected provider fraud, be able to respond appropriately with notifications of key stakeholders within required timeframes
• Ability to coordinate and track overpayment recoveries, document and work with collection agency to collect when necessary; prepare end of year overpayment reports for government clients
• Data mining skills – collecting, collating, analyzing and interpreting