Fraud Investigator (Medicare & Medicaid)

This position works as an integral member of a multidisciplinary team for a federal government contract to perform investigations to identify fraud, waste and abuse in the billing by Medicare and Medicaid providers.

• Full-Time with full benefits
• Position is contingent upon contract award to Catapult (estimated award is from 9/1/17 through 3/31/18), resumes will be collected until contract award when phone interviews will begin
• Work location is an office to be determined in Nashville, TN or Miami, FL
• Travel may be required 5% to 10% of the time
• Multiple positions may be filled at varying experience levels (entry-level, mid-career and lead/senior)

Minimum Qualifications:

• High School degree required
• At least 1 year of experience in program integrity investigation/detection or a related field that demonstrates expertise in reviewing, analyzing/developing information, and making appropriate decisions
• Must have and maintain a valid driver’s license issued by the state of residence
• Intermediate knowledge of Microsoft Word, Excel, Outlook and PowerPoint
• Highly-motivated & detail-oriented professional with excellent analytical, organizational, verbal & written communication, and follow-up skills

Preferred Qualifications:

• Bachelor’s or Master’s degree in Criminal Justice, Statistics, Data Analysis, Accounting, Finance, Healthcare, or Business-related field
• 2 to 15 years of related full-time work experience
• Preference is given to those candidates with experience in fraud detection and investigation within the Medicare program
• Experience working with Medicare and a Medicaid program in one of the following states: VA, WV, TN, NC, SC, AL, GA or FL
• Certified Fraud Examiner (CFE) certification

Responsibilities:

• Conducts independent investigations resulting from the discovery of situations that potentially involve fraud, waste, or abuse.
• Utilizes data analysis techniques to detect aberrancies in Medicare claims data, and proactively seeks out and develops leads received from a variety of sources (e.g., CMS, OIG, fraud alerts).
• Completes written referrals to law enforcement and takes steps to initiate recoupment of overpaid monies.
• Responds to requests for information from law enforcement.
• Maintains cases referred to law enforcement. Maintains the “Zone Restriction” (previously called “Do not Pursue”) list.
• Reviews information contained in standard claims processing system files (e.g., claims history, provider files) to determine provider billing patterns and to detect potential fraudulent or abusive billing practices or vulnerabilities in Medicare policies and initiates appropriate action.
• Makes potential fraud determinations by utilizing a variety of sources such as the ZPIC’s internal guidelines, Medicare provider manuals, Medicare regulations, and the Social Security Act.
• Develops and prepares potential Fraud Alerts and Program Vulnerabilities for submission to CMS; shares information on current fraud investigations with other Medicare contractors, law enforcement, and other applicable stakeholders.
• Reviews and responds to requests for information from Medicare stakeholders as assigned; pursues applicable administrative actions during investigation/case development (e.g., payment suspensions, civil monetary penalties, requests for exclusion, etc.)
• Participates in onsite audits in conjunction with investigation development.
• Provides support of cases at hearing/appeal and ALJ level.
• Maintains chain of custody on all documents and follows all confidentiality and security guidelines.
• Compiles and maintains various documentation and other reporting requirements.
• Performs other duties as assigned by PI Management that contribute to ZPIC goals and objective s.

Abilities Required:

• While performing the duties of this job the employee is regularly required to sit and use hands to finger, handle, or feel while typing at a computer keyboard.

• The employee is occasionally required to stand, walk, reach, or lift objects up to 10 pounds.

• The employee is frequently required to talk or hear. The vision requirements include: close vision.