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Years of Experience
Date Last Verified
ProfileFraud Investigator - Long Term Care The candidate will support firm by complying with state and federal laws to meet client contractual requirements. Will work with multiple business units on coordination, identification, mitigation, and reporting of incidents and risks related to anti-fraud activities. Responsible for effective research, analysis, and accurate documentation for reporting to clients and firm's leadership. Coordinate and perform investigations. Prepare responses for suspected or alleged fraud. Work closely with cross-functional leaders to ensure appropriate resolution, accurate reporting and tracking to meet client specific service level agreements. Participate as a subject matter expert during client implementations, audits and system or process development. Other duties and projects as assigned including triaging, quality review and time managing multiple competing priorities.
Qualification and Experience
The candidate should have Bachelor's degree in criminal justice, business administration, insurance/healthcare administration or paralegal studies. Demonstrated experience may be considered in lieu of degree is essential. Should have 5+ years of health care fraud investigation experience. Must have clear understanding of investigative techniques and the laws pertaining to insurance claims and mandated fraud reporting as well as a general knowledge of legal principles, civil and criminal, pertinent to the investigation of claim activity. Experience conducting investigative research, and effective analytical skills with quantitative, creative thinking and problem solving skill is essential. Strong verbal and written communication skill is essential. Should be skilled using Microsoft Word, Excel, Outlook, Access and research tools. AHIP designations as: Certified Fraud Examiner, Health Care Anti-Fraud Associate, Long Term Care Professional, HIPAA Professional, Managed Care Professional is preferred. Working knowledge of medical terminology is preferred. Training in quality management programs such as Six Sigma or industry equivalent is preferred. Experience with NILS Insource, LexisNexis, or Westlaw is preferred.