Healthcare Fraud Investigator – Immediately

Position Purpose:

The purpose of this position is to provide clinical and domain expertise to validate and improve the alerts generated by an analytic fraud, waste, and abuse solution.

Primary Duties & Responsibilities:

The incumbent will work independently and in collaboration with clinicians, investigators, and analytic staff to review fraud alerts related to possible medical and pharmaceutical provider and claim fraud, waste, and abuse. Activities will include:

• Review of algorithms in use by the solution including evaluating the usefulness of the algorithms for uncovering fraud, waste, and abuse
• Review of basic patient and provider information in addition to claims detail data using a web interface
• Provide opinion on alerts most likely to be deemed true fraud, waste or abuse upon full investigation.
• Provide feedback concerning improvements to algorithms and methodologies in order to improve alerts and triage process
• Discuss results of reviews with persons who perform onsite audits of providers, facilities, and pharmacies to further refine algorithms
• Work with statisticians and programmers to automate improved algorithms and the production of fraud, waste, and abuse alerts

Qualification Requirements:

Three years of experience clinical and fraud investigation experience. Experience with government programs such as Medicare, Medicaid, and or SCHIP preferred. Minimum educational requirement is BSN. License required is registered nurse (RN). Preferred certifications include Certified Professional Coder (CPC) and/or Accredited Health Care Fraud Investigator (AHFI).

Job Type and Other Requirement:

The position is contract with remote location.

Job Type: Contract

Required education:

• Bachelor’s

Required experience:

• Medicare, Medicaid, and/or SCHIP: 3 years
• clinical fraud investigation: 3 years
• HEIDIS/STARS: 3 years

Required licenses or certifications:

• CPC
• Registered Nurse (RN)
• AHFI