Health Fraud Investigator

Full-Time Permanent Employee

Remote

http://www.integritym.com

About Us

Integrity Management Services, Inc. (IntegrityM) is an award-winning, women-owned small business specializing in assisting government and commercial clients in compliance and program integrity efforts, including the prevention and detection of fraud, waste and abuse in government programs. Results are achieved through data analytics, technology solutions, audit, investigation, and medical review.

At IntegrityM, we offer a culture of opportunity, recognition, collaboration, compassion and supporting our community. We thrive off of these fundamental elements that make IntegrityM a great place to work. Our small, flexible workplace offers an exceptional quality of life and promotes corporate-driven sustainability. We deliver creative solutions that exceed goals and foster a dynamic, idea-driven environment that nurtures our employees’ professional development. Large company perks…Small company feel!

Job Summary

Independently performs in-depth evaluation and makes field level judgments related to investigations of potential Medicare fraud, waste and abuse investigations or cases that meet established criteria for referral to the Centers for Medicare & Medicaid for administrative action or to the OIG for criminal action.

Essential Duties and Responsibilities include the following. Other duties may be assigned.

• Utilizes leads provided by the team and referrals from government and private agencies, works with the team to prioritize complaints for investigation, and then investigates, conducts interviews and reviews information to make potential fraud determination.
• Determines investigation or case appropriateness of fraud, waste and abuse issues in accordance with pre-established criteria.
• Based on contract requirements, may refer potential adverse decisions to the Lead Investigator/Manager/Medical Director or designee.
• Conducts interviews of witnesses, informants, and subject area experts and targets of investigations.
• Identifies, collects, preserves, analyzes and summarizes evidence, examining records, verifying authenticity of documents, may provide information to support the preparation of attestations/referrals or supervising the preparation of attestations/referrals as needed.
• Drafts investigation reports, evaluates investigation reports, and promotes effective and efficient investigations.
• Initiates and maintains communications with law enforcement and appropriate regulatory agencies including presenting or assisting with presenting investigation or case findings for their consideration to further investigate, prosecute, or seek other appropriate regulatory or administrative remedies.
• Testifies at various legal proceedings as necessary.
• Identifies opportunities to improve processes and procedures.
• Has the responsibility and authority to perform their job and provide customer satisfaction.

Supervisory Responsibilities

This job has no supervisory responsibilities.

Requirements

Competencies

To perform the job successfully, an individual should demonstrate the following competencies:

Analytical - Synthesizes complex or diverse information; Collects and researches data; Uses intuition and experience to complement data.

Problem Solving – Gathers and analyses information skillfully; Identifies and resolves problems.

Written Communication - Writes clearly and informatively; Able to read and interpret written information.

Judgment - Supports and explains reasoning for decisions.

Qualifications

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education and/or Experience

A Bachelor's Degree or one or more of the following:

• certification in an applicable program such as Certified Fraud Examiner or Accredited Healthcare Anti-fraud Investigator Certification
• successful completion of a law enforcement academy
• experience in health care fraud investigation/detection.

Must possess experience in a federal or state healthcare programs or a related field that demonstrates expertise in reviewing, analyzing, and making appropriate decisions.