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Years of Experience
Date Last Verified
Senior Investigator The candidate will be responsible for the independent identification, investigation and development of complex cases against perpetrators of healthcare fraud in order to recover corporate and client funds paid on fraudulent claims. Will deal with claim reviews for appropriate coding, data mining, entity review, law enforcement referral, and use of proprietary data and claim systems for review of facility, professional and pharmacy claims. Independently identify and develop enterprise-wide specific healthcare investigations and initiatives that may impact more than one company health plan, line of business and/or state. May interface internally with Senior level management and legal department throughout investigative process. May assist in training of internal and external entities. Assist in the development of policy and/or procedures to prevent loss of company assets. May be called upon to represent the company in court proceedings regarding research findings. Health insurance experience required with understanding of health insurance policies, health insurance claims handling and provider network contracting. Develop and maintain a high degree of rapport and cooperation with the Federal, State and local law enforcement and regulatory agencies which can assist in investigative efforts.
Qualification and Experience
The candidate should have a BA/BS degree with 5+ years of related experience in healthcare insurance and healthcare insurance investigation, law enforcement or any combination of education and experience which would provide an equivalent background. Professional certification of CFE, AHFI, CPC, Paralegal, RN, J.D. degree or other job related designation preferred. Knowledge of Plan policies and procedures in all facets of benefit programs management with heavy emphasis in negotiation preferred.
Requisition ID: PS2425
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