Skills/Qualifications

HS diploma or GED or Bachelor’s degree
8 years of experience in fraud, waste & abuse (FWA) investigations or special investigations unit (SIU) including 1 yr experience working with Medicaid
Must hold one of the following certifications :
CPA (Certified Public Accountant)
CFE (Certified Fraud Examiner)
AHFI (Accredited Health Care Fraud Investigator)
INT – POPC Intermediate Peace Officer Proficiency Certificate

Strong analytical and research skills.
Proficient in researching information and identifying information resources.
Exercises independent judgement and uses available resources and technology in developing evidence and supporting allegations of fraud, waste, and abuse.
Knowledge of medical terminology and/or experience with CPT codes, and ICD-9, ICD-10 coding.
Knowledge of suspected FWA trends and matters of interest to law enforcement and regulators.
Strong communication and customer service skills.

Job Duties

Coordinates with subcontractors on overseeing investigations of Fraud, Waste & Abuse (FWA).
Manages a large fraud investigation caseload and investigates allegations relating to potential health care fraud perpetrated by Medicaid and commercial providers, vendors, and enrollees.
Provides internal and external case updates on progression of investigations in coordination with SIU team members and other departments, including recommendations on further action and/or resolution, as needed.
Continually interfaces with members, vendors, pharmacies, providers and other third parties via telephone, e-mail, and on-site visits as needed to identify, further, and conclude ongoing investigations.
Implements processes and procedures to: prevent, detect, investigate and report FWA to appropriate regulatory agencies.
Provides inter-departmental input regarding controls for preventing and monitoring FWA issues.
Proactively identifies trends and aberrant activity to generate leads for FWA investigations.
Performs special assignments related to FWA as assigned by the Director of Controls and Compliance.

For subcontractor,