Fraud and Waste Investigator, Special Investigations Unit: The Fraud and Waste Investigator, Special Investigation Unit is responsible for effectively leading a team of investigators in the day-to-day work of investigations providing support to both marketing and medical investigators by carrying out preliminary investigations and conducting data analysis of alleged Fraud, Waste and Abuse by providers, members, representatives, and others.
Special Investigations Unit Manager works within specific guidelines and procedures; applies advanced technical knowledge to solve moderately complex problems; receives assignments in the form of objectives and determines approach, resources, schedules, and goals.
Fraud and Waste Investigator Jobs in USA 2019
ROLES AND RESPONSIBILITIES:
Lead the Marketing Incidents Committee in effectively reporting and communicating trends, cases, and committee directed follow-ups such as disciplinary actions
• Assists in coordinating the investigation with law enforcement authorities
• Leads team/investigators in assembling of evidence and documentation to support successful adjudication
• Monitors/Leads investigations to ensuring the appropriateness of billing practices using a variety of investigational tools
• Prepares complex investigative and audit reports
• Decisions are typically related to resources, approach, and tactical operations for projects and initiatives involving own departmental area
• Requires cross-departmental collaboration, and conducts briefings and area meetings; maintains frequent contact with other managers across the department
• Work closely with business unit leadership and other key operational staff such as Sales Management and Training, Regulatory, Privacy and Human Resources to communicate potential fraud, waste, and abuse
• Confers with investigators to review the evidence and determine further investigative step
• Conducts investigations into allegations of misconduct and fraud
• Assists with reporting investigative findings
• Participates in Fraud, Waste and Abuse detection, and prevention.
Ensures timely reporting of findings and trends
• Identifies and suggests process improvements
• Coordinate resources to property investigate external risks associated with organized fraud
• Maintain standards, reporting procedures, statutory compliance, and the efficient operation of the assigned team
• Develops and presents verbal and written investigative and management reports
• Serves as a resource and mentor to team members
• Assists in the delivery of fraud awareness training initiatives throughout Assurant
• Acquires and applies a working knowledge of state laws and regulations pertaining to insurance fraud
• Proficient in handling insurance claim investigations.
• Knowledge of Medicare and Medicaid.
• Knowledge of medical claims processing and investigations.
• Knowledgeable about applicable fraud statutes, CMS guidelines, Federal and State requirements
• Excellent communication skills, written and verbal
• Strong organizational and project management skills
• Strong Analytical skills
• Proven ability to work in a fast-paced environment meeting service standard
• Detail oriented with a commitment to excellence
• Ability to think creatively and make appropriate decisions
• Bachelor’s Degree in health, criminal justice, or legal related field
• 2-4 years of health insurance claims or Medicaid agency experience
• Minimum of 1 year of supervisory/management or team lead experience including coaching and developing employees
• Basic office computer skills and experience with Microsoft Office
• Preferred Experience, Skills, and Knowledge
• Excellent verbal and written communications skills
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