Medicaid – Medicare: Healthcare Fraud Investigator – REMOTE
CoventBridge Group is the leading worldwide full-service investigation solutions company providing: Surveillance, SIU and Compliance, Claims Investigation, Counter-Fraud Programs, Desktop Investigations, Social Media, Record Retrieval, Canvasses and Vendor Management programs. With offices in the UK and U.S. the company provides top tier data privacy and security practices, deploys robust case management technology customized to clients’ needs and delivers worldwide coverage via its 1000 employees and affiliates worldwide.
About the Opportunity:
The Medicaid – Medicare Healthcare Fraud Investigator, also called, Program Integrity Action Analyst II will primarily be responsible for performing investigations, site visits once evaluations and developments of complaints determine an investigation is warranted.
In assuming this position, you will be a critical contributor to meeting CoventBridge Group’s objective: To provide services to our clients that exceed their expectations and contribute to improved healthcare delivery by identifying and eliminating fraud, waste and abuse.
This position will report directly to the Program Integrity Supervisor and will work in our Grove City, OH office or if not local, remotely from a home office.
- Perform evaluation and development of complaints to determine if referral as an investigation is warranted
- Conduct independent reviews resulting from the discovery of situations that potentially involve fraud or abuse
- Utilize basic data analysis techniques to detect aberrancies in Medicare and Medicaid claims data, and proactively seeks out and develops leads received from a variety of sources (e.g., CMS, OIG, 1-800-MEDICARE, and fraud alerts)
- Review information contained in standard claims processing system files (e.g., claims history, provider files) to determine provider billing patterns and to detect potential fraudulent or abusive billing practices or vulnerabilities in Medicare and Medicaid policies and initiates appropriate action
- Make potential fraud determinations by utilizing a variety of sources such as internal guidelines, Medicare and Medicaid provider manuals, Medicare and Medicaid regulations, and the Social Security Act
- Compile and maintain documentation and information related to investigations, cases, and/or leads
- Participate in onsite audits in conjunction with investigation development
- Develop and prepare potential fraud alerts and program vulnerabilities for submission to CMS; share information on current fraud investigations with other Medicare and Medicaid contractors, law enforcement, and other applicable stakeholders
- Perform other duties as assigned by PI Supervisor or PI Manager that contribute to task order goals and objectives
- At least 1 year of experience in program integrity investigation/detection or a related field that demonstrates expertise in reviewing, analyzing/developing information, and making appropriate decisions.
- Excellent oral, written and verbal skills
- Ability to work independently with minimal supervision
- Knowledge of statistics, data analysis techniques, and PC skills are preferred
- Experience with Microsoft Excel preferred
- At a minimum, a high school diploma, with preference given to those candidates who have successfully completed college or technical degree programs related to the position (e.g., criminal justice, statistics, data analysis, etc.)
- Preference will also be given to those individuals that have attained the Certified Fraud Examiners (CFE) designation or Accredited Health Care Fraud Investigator (AHFI)
- Medical, Dental, Vision plans
- Life, LTD and STD paid by the employer
- 401(k) with company match up to 4%
- Paid Time Off and company paid holidays
- Tuition assistance after 1 year of service
*CoventBridge is proud to be an EEO-AA employer M/F/D/V.*
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