This position is responsible for comprehensive management and ownership of fraud, waste and abuse investigations including development and presentation of investigative results. This individual carries out analytical and process management tasks with a high degree of autonomy. This individual serves as a corporate resource on fraud, waste and abuse issues and recommends cost containment projects with an emphasis on fraud prevention. INVESTIGATIONS
Prioritize, triage and manage workload to meet internal performance metrics, regulatory and contractual requirements
Use independent judgment to create investigative work plans and develop case strategies based upon analysis of referral data and contractual/regulatory requirements
Analyze data and select audit samples using various sampling methodologies
Plan and conduct desk audits, field audits and/or site visits
Collect and analyze information to evaluate facts and circumstances through an extensive review of data from professional and facility providers, member data, contractual relationships, payment policies, Medicaid/Medicare rules and statutes, etc.
Conduct research on medical policies and practices, provider characteristics, and related topics
Interview patients, providers, provider staff, and other witnesses/experts
Prepare correspondence
Obtain and preserve physical and documentary evidence to support investigations
Maintain comprehensive case files
FRAUD, WASTE AND ABUSE DETECTION
Triage and prioritize leads from internal and external sources
Use knowledge of healthcare coding conventions, fraud schemes, and general areas of vulnerability, reimbursement methodologies, and relevant laws to find suspicious patterns in claims data, provider enrollment data, and other sources
Remain up to date on published fraud cases, schemes, investigative techniques and methodologies, and industry trends
PACKAGING OF FINDINGS AND RECOMMENDATIONS
Organize data and prepare a written summary of investigative steps, conclusions, recommendations with attention to detail and a high level of accuracy
Prepare clear and concise investigatory reports to support findings of potential fraud, waste and abuse
CASE RESOLUTION
Identify, communicate and recover losses as deemed appropriate
Present case to internal department(s), law enforcement and/or regulatory agencies
Support legal proceedings as needed, including testifying in court or working with law enforcement personnel to prepare cases for civil or criminal actions
Negotiate settlement agreements with subjects and/or attorneys
Assist in preparation, execution, and follow-up of settlement agreement terms
CUSTOMER INTERACTIONS
Make presentations to customers, prospects, conference audiences, and law enforcement
Collaborate, consult, and coordinate regularly with clients on the status and direction of assignments
Develop and maintain contacts/liaisons with law enforcement, regulatory agencies, task force members, other company SIU staff and external contacts involved in fraud investigation, detection and prevention
MISCELLANEOUS DUTIES
Provide guidance and training to SIU Investigators regarding case strategy, best practices, industry standards, Medicare/Medicaid requirements, industry trends, fraud schemes and other related areas
Drive department efficiency and effectiveness through the recommendation and development of procedures and process flows and the implementation of industry best practices
Represent client at industry task force meetings and meetings with regulatory agencies
Measure and report performance metrics
Identify opportunities and make recommendations for reduction of exposure to fraud, waste and abuse
Consult on and develop anti-fraud policies and procedures
Other duties as assigned.
The job duties listed above are representative and not intended to be all-inclusive of what may be expected of an employee assigned to this job. A leader may assign additional or other duties which would align with the intent of this job, without…