Integrity Management Services is hiring a
Healthcare Fraud Investigator

Summary

The job is for an Investigator at Integrity Management Services, Inc., a woman-owned small business that helps government healthcare organizations prevent and detect fraud and abuse. The role involves maintaining confidentiality, adhering to privacy and security protocols, conducting data analysis, background research, interviews, and coordinating with law enforcement agencies, legal counsel, and state and federal program administration agencies.

Requirements

• High school diploma required, Bachelors degree preferred (e.g., law enforcement investigation, statistics, data analysis)
• Three to five years’ experience in healthcare fraud investigation/detection
• Medicare and Medicaid investigative experience preferred (e.g., Part C, Part D, DME, Home Health and Hospice)
• Strong investigative, analytical and problem-solving skills
• Strong communication and organization skills
• Experience in reviewing claims for technical requirements, performing medical review, and/or developing fraud cases
• Strong PC knowledge and skills
• Must pass post hire background screening checks

Responsibilities

• Maintains strict confidentiality and security of all sensitive and/or business confidential information obtained or accessed during the course of business and/or contract operations
• Adheres to all IntegrityM and/or client privacy and security protocols governing sensitive and/or business confidential information
• Ensures compliance with all applicable privacy and security training requirements
• Conducts data analysis of claims data to identify instances of suspected healthcare fraud, waste, and abuse in Medicare Part C and Part D benefits
• Conducts background research of suspect providers to identify information regarding adverse business relationships, disqualifying violations, exclusions or licensing sanctions
• Reviews policies, regulations and instructions relevant to supporting suspected healthcare fraud, waste and abuse violations and provides that information as necessary in support of data analysis findings
• Documents all findings relevant to support recommendations for further analysis or investigation referrals
• Collects and reviews records and documents relevant to investigation development
• Conducts interviews and maintains accountability and safeguards any items considered to be of evidentiary value in accordance with established guidelines and rules of evidence
• Coordinates investigations with appropriate federal and state law enforcement agencies, legal counsel and state and federal program administration agencies
• Testifies at various legal proceedings as necessary
• Coordinates with medical reviewers, data analysts, program managers, SMEs, and other staff as appropriate to develop or unfound investigations
• Inputs data into appropriate database tracking programs as needed in accordance with established rules
• Coordinates with clients in support of findings and recommendations resulting from investigations and data analysis
• Provides input into development of new fraud scheme studies
• Identifies opportunities to improve processes and procedures
• Meets all established deadlines
• Works with internal resources and external agencies to develop cases and corrective actions, as well as responds to requests for data and support
• Maintains fraud case development quality standards so that proper case development is ensured, and quality cases are fully prepared
• Maintains proper and timely updates in appropriate tools and applications for their investigations. Case development databases and documents
• Completes all requests for information from law enforcement within required timeframes
• Improves client processes so that efficiencies are achieved to complete a task and ISO 9001:2008 related activities are completed
• Enhances fraud detection and improves interdepartmental workflow so that it is evident the client is being proactive in its efforts to identify potentially fraudulent schemes
• Conducts on-site visits and/or interviews as required for investigation
• Performs ad hoc tasks/duties as assigned
• Maintains a professional appearance, workplace demeanor and work schedule compliance

Preferred Qualifications

Certified Fraud Examiner (CFE) or Accredited Health Care Fraud Investigator (AHFI)