Job Description

Job Responsibilities:

• Independently analyze public and HAP internal data and information to develop preliminary assessment of facts to determine if full investigation is warranted. Develop investigative strategy and approach to complete investigation.
• Assembles evidence and documentation to support successful adjudication, where appropriate.
• Conducts on-site audits of provider records ensuring appropriateness of billing practices.
• Conduct interviews with providers, employees, members, and witnesses as part of the investigative process.
• Prepares complex investigative and audit reports with the ability to present investigation summaries that include metrics, trends, and schemes to various stakeholders, including enforcement agencies.
• Must be able to craft a well organized referral explaining the alleged fraud in a fraud referral to regulators.
• Coordinates investigation with law enforcement authorities and regulatory agencies.
• Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas.
• Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed.
• Follows established guidelines/procedures.
• Censure that the compliance department meets the required OIG effective compliance program elements by promptly responding to identified issues and concerns within the organization.
• Work independently and manage a caseload which include investigations, identifying schemes, tracking, trending, and reporting instances of non-compliance.
• Respond to alleged violations of rules, regulations, policies, procedures, and Code of Conduct by evaluating or recommending the initiation of investigative procedures. Ensure policies and procedures are followed for the general operation of the compliance program and its related activities to prevent illegal, unethical, or improper conduct.
• Independently move an investigation to the next step in the investigative process with minimal assistance and errors. This includes from the opening to final disposition.
• Independently develop new cases based on proactive data mining efforts.
• Respond to a complaint, take statements, document effectively and identify any fraud, waste or abuse.   
• Identify patterns and trends to generate new investigative leads.
• Collaborative Skills: Demonstrates strong teamwork and collaboration abilities, effectively working with other investigators to achieve common goals and take responsibility for team outcomes while contributing to the overall success of the team.
• Adaptability: Shows flexibility in adapting to different roles and responsibilities within the team, contributing to various aspects of investigations as needed.
• Demonstrated experience with Managed Care products such as Medicare, Medicaid, ACA, and commercial insurance. 
• Develop and facilitate training regarding Fraud Waste and Abuse requirements, HFH Non-retaliation policy, Code of Conduct, and government program requirements.
• Perform other related duties as assigned.

Skills:

• Experience working with RATSTATS or similar programs for sampling and extrapolation.
• Proficiency using excel including ability to analyze large data sets to identify trends, anomalies, and opportunities for improvement, using data visualization techniques to present findings effectively
• Ability to use excel or other Microsoft software to automate repetitive processes and enhance existing workflows through advanced Excel features, including macros, pivot tables, complex formulas and power query
• Experience with Microsoft Power BI and knowledge of sequel preferred.
• Excellent verbal, written and presentation skills
• Ability to work with individuals of diverse backgrounds at various levels
• Objective and creative analytical and auditing skills
• Knowledge of various product lines in health care industry
• ·Strong organizational, interpersonal, and communication skills
• Inquisitive nature with ability to analyze data to metrics
• Knowledge of healthcare payment methodologies
• Knowledge and experience with FACETs or similar claim systems.
• Strong personal and professional ethics

Education/Experience:

• Bachelors Degree (Masters or Law degree preferred), CFE or AHFI certification, Minimum of 3 years experience in healthcare, pharmacy technician, claims adjudication, medical billing/coding, nursing or law enforcement, Previous experience working for a health insurance payer, Minimum of 2 years experience conducting comprehensive investigations preferably with interaction with state, federal and local law enforcement agencies, Previous experience with FACETs system

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