Senior Investigator
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Job Description
Senior Investigator managing fraud, waste, and abuse audits across independent teams at PacificSource. Conducting investigations and ensuring compliance with regulations and company policies.
Responsibilities:
- Independently plan, conduct, and manage prompt, thorough onsite and desk-top investigations of health care claims.
- Thoroughly document investigative findings and actions to create comprehensive case files in accordance with established policies and procedures.
- Proactively utilize available analytic resources to identify patterns of potential Fraud, Waste and Abuse, initiating audits when necessary.
- Conduct fact-finding interviews with internal staff, external providers, patients and other relevant parties regarding medical and behavioral health services initiating investigations when necessary.
- Utilize available Open Source Intelligence (OSINT) tools to verify provider licenses, research criminal history, disciplinary actions, financial assets and liabilities.
- Attend and participate in regional FWA Task Force and other state or federal meetings.
- Establish and maintain a comprehensive knowledge and understanding of current state and federal reporting requirements ensuring FWA reporting is received, summarized, catalogued, and disseminated to the appropriate agencies.
- Ensure regulatory reporting is developed, accurate, and submitted timely.
- Serve as an internal Subject Matter Expert (SME) on matters related to auditing and FWA.
- Develop and conduct internal FWA related training.
- Collaborate with government agencies during audits, investigations and Requests for Information (RFI).
- Present and discuss case findings and recommendations in case review meetings with department and company management.
- Participate in the development and presentation of FWA reporting for the Corporate Compliance Committee and the Audit and Compliance Committee of the Board.
- Coordinate and manage the production of investigative materials in support of settlement negotiations.
Requirements:
- Minimum of 4 years of experience conducting complex healthcare fraud investigations required.
- Significant experience in facilitating audit activities across specialized teams required.
- Ability to effectively and professionally communicate with internal and external stakeholders, in both written and verbal form, required.
- Ability to independently research, understand and interpret complex healthcare claims data, civil and criminal laws, and contract requirements required.
- Experience in navigating case management, claims and OSINT platforms preferred.
- Bachelor’s degree in business administration, criminal justice, or related field or a combination of equivalent education and experience is required.
- Ability to obtain Certified Fraud Examiner (CFE) or equivalent certification within 24 months of employment required.
Benefits:
- Flexible telecommute policy
- Medical, vision, and dental insurance
- Incentive program
- Paid time off and holidays
- 401(k) plan
- Volunteer opportunities
- Tuition reimbursement and training
- Life insurance
- Options such as a flexible spending account
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