Investigator III

Job description

#LI-Hybrid - Perform FWA incident oversight and SIU staff development activities: - Provide direct oversight to other SIU staff by reviewing and providing feedback to Investigators for written correspondences and regulatory referrals. - Provide day-to-day advice/guidance to SIU staff on FWA incidents including decisions to open and/or close SIU incidents. - Create, update and present training sessions for all SIU staff, internal and external entities covering special investigations workflows and processes, information and data systems, and subject-matter specific topics (e.g., specialized information sessions about medical/coding topics and FWA trends/schemes; Special Investigation case studies). - SIU case investigation management, resolution and prevention. - Initiate, analyze, develop, and resolve proactive FWA cases using Fraud Detection Software, advance/extensive knowledge of benefits, claims, rules, processes, and other relevant topics (e.g., medicine, pharmacy, law, accounting). - Maintain extensive documentation and evidence for SIU cases. - Recommend and implement preventive measures to combat FWA schemes including, but not limited to provider education, policies, claims...