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. This individual p erforms in-depth evaluation and analysis of potential fraud cases and requests for information using claims information and other sources of data. This individual supports the development of complex cases that involve high dollar amounts, sensitive issues, or that otherwise meet criteria for referral to law enforcement, recoupment of overpayment, and/or administrative action based on reactive and proactive data analysis.

• Full-Time with full benefits
• Work location is an office in: Brookfield, WI; Lisle, IL; Bingham Farms, MI; Grove City, OH; or Omaha, NE. Highly qualified candidates with health care program integrity experience may be approved to work from home in MN, WI, IL, MI, OH, KY, IA, MO, NE, IN or KS.
• Travel may be required 5% to 10% of the time

Minimum Qualifications:

• High School diploma required
• At least 1 year of experience in program integrity investigation/detection (also known as fraud 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
• Knowledge of statistics, data analysis techniques and advanced computer skills
• Experience in fraud detection and investigation within the Medicare program
• Experience working with a Medicaid program in one of the following states: MN, WI, IL, MI, OH, KY, IA, MO, NE or KS
• 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.
• Refers suspected instances of apparent unethical or improper practices or unprofessional conduct (e.g. quality of care concerns) to the appropriate entity. For Medicaid-related issues, shall coordinate with the State Program Integrity Unity and any other entities at state request within the state responsible for ethical, professional or quality of care issues. For Medicare-related issues, shall coordinate with the Quality Improvement Organization (QIO). For issues involving both programs, shall coordinate across these entities.
• Responds to requests for information from law enforcement. Maintains cases referred to law enforcement.
• 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 UPIC’s internal guidelines, Medicare and Medicaid provider manuals, Medicare and Medicaid 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 and Medicaid 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 UPIC 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.