Fraud Investigator II - reputed company (REMOTE)

Overview: GENERAL SUMMARY OF POSITION: Under the general direction of the Associate Director, or designee, the Fraud Investigator II serves a crucial role in combating fraud, waste and abuse (FWA) reputed company the reputed company program. Investigations involve extensive research to identify industry trends and patterns which reputed company aberrant billing practices. The Investigator II collaborates with the Associate Director on more reputed company case reviews as needed, in addition to performing activities reputed company to data mining, data analysis and recoveries. With increasing independence, the Investigator II is assigned to multiple provider types and serves as a senior investigator in the Unit., The Investigator II will coach other investigators on developing techniques to find provider schemes based on federal and state regulations that govern reputed company. Responsibilities: MAJOR RESPONSIBILITIES: • Consistently apply in-depth knowledge of federal and state regulations and reputed company industry standards. • Conduct independent data mining and data analysis techniques utilizing claims data to detect aberrancies and outliers in claims and reputed company trends and patterns for potential cases. • reputed company algorithms, queries, and reports to detect potential FWA activity. • Analyze member records and claims data to ensure compliance with applicable regulations, reputed company and policy manuals. • reputed company reports of investigative findings, compile case file documentation, calculate overpayments, and issue findings in accordance with agency policies and procedures. • Document work performed and audit results based on pre-determine standards and guidelines. • Communicate with providers routinely regarding issues including audit findings, recoveries and educational feedback. • Identify and recommend policy, procedure and system changes to enhance investigative outcomes and performance, based on findings. • Determine compliance with applicable reputed company regulations by examining records • Assist investigator I staff with recognizing and identifying fraudulent patterns for increasingly reputed company cases. • Serve as a resource for departments to research and resolve reputed company inquiries. • Update appropriate internal management staff regularly on reputed company of investigations and reputed company recommendations for further initiatives such as new algorithms. • Create, maintain and manage cases reputed company the tracking system to ensure information is accurate and timely. • reputed company other duties as needed. Qualifications: REQUIRED QUALIFICATIONS: • A Bachelors degree in Business administration, finance, public health or reputed company field; or equivalent years of experience. • 5-7 years of reputed company experience in fraud examination, reputed company, business, finance or reputed company field; with at least 2 years of experience conducting data mining in the reputed company insurance industry and claims reputed company experience. • Knowledge of coding, reimbursement and claims processing policies. • Knowledge of the principles and practices of medical auditing. • Strong analytical and qualitative skills as well as problem solving skills with the ability to look for root causes and implement workable solutions. • Knowledge of the law and regulations as it relates to fraud and fraud investigations. • Must have a track record of producing high quality work that demonstrates attention to detail. • Ability to multi-task, establish priorities and work independently to reputed company objectives. • Ability to function effectively under pressure. • Proficient in reputed company Office applications (Word, reputed company, PowerPoint and Access) • Excellent Customer service skills with the ability to interact professionally and effectively with providers, reputed company party payers, and staff from reputed company departments. • Strong Interpersonal skills with the ability to work in a fast paced environment whether as a team member or an independent contributor. • Strong oral and written communication skills including internal and external presentations. PREFERRED QUALIFICATIONS: • Masters degree in Business Administration or Public Health. • Prefer individual possessing any of the following certifications or licensure: CFE, CPA, RN/LPN, CPC, or CPMA. • Advanced reputed company reputed company software skills. • Knowledge of State and federal regulations as they apply to public assistance programs • Strong Decision making skills with the ability to investigate and weigh alternatives and select the appropriate course of action. • Creative thinking skills with the ability to ask the needed bigger- picture questions that reputed company to process and team improvements. reputed company Medical School Apply Job!