Investigator » EltasJobs

Hennepin Health (HH) is seeking a Senior Investigator to lead Special Investigation Unit (SIU) functions. The Senior Investigator will be responsible for the development of a comprehensive program to combat suspected fraud, waste or abuse (FWA) and leading FWA investigations from triage to conclusion.

HH is a not-for-profit, state-certified health maintenance organization (HMO) and an enterprise initiative of Hennepin County. HH serves the county’s diverse safety net population and publicly funded health care recipients. Its mission is to help people improve their health through personal service; its vision is to become the leader in eliminating health care disparities. Because of HH’s affiliation with Hennepin County, services for its members are enhanced through a close linkage with social services and other programs offered by the county

This posting will remain open until filled.

Employees receive a combination of generous benefits and positive workplace culture not found at other organizations. This includes meaningful work, competitive pay, real work-life balance, generous benefits and opportunities to grow. We want our employees to succeed-not only at work, but as they move through life and its milestones. Learn more at https://www.hennepin.us/employees.

Your future. Made here.

The primary duties and responsibilities of this position include:

Direct the activities of the FWA program to maximize cost avoidance and recovery of medical assistance benefits from other liable third parties in accordance with state and federal laws, regulations and policies.
Assist in developing organizational and operating policies and procedures for FWA to operationalize; maximize efficiency and understanding for all parties including medical providers, vendors, HH staff, and recipients understand their roles.
Serve as the primary Special Investigation Unit’s investigator for all FWA cases.
Collect evidence and build a case supporting billing or payment abnormalities.
Manage the SIU caseload by making independent decisions and presenting well- founded recommendations to the leadership team.
Collaborate with multiple divisions of Hennepin Health to lead comprehensive efforts in preventing FWA.
Complete claims data and communicate findings to internal and external business partners.
Develop and expand on existing analytical tools to proactively pursue potential areas of FWA.
Work FWA cases from multiple sources including members, providers, pharmacies, dental providers and personal care attendants that cross all Hennepin Health products.
Utilize information from claims data analysis, members, providers and employees.
Document all relevant findings pursuant to HH policies and procedures, including making appropriate referrals to regulatory authorities.

Best Qualified Candidates will have:

One of the following:
- Bachelor’s degree or higher in criminal justice, health care administration, or other field appropriate to the position and four or more years of experience with healthcare fraud investigations.
- Eight or more years of experience with healthcare fraud investigations.
Certified Fraud Examiner (CFE) or Accredited Health Care Fraud Investigator (AHFI).
Experience:
- With Medicaid, MinnesotaCare, Medicare or publicly funded health programs.
- With claims or claims processing, including knowledge of medical terminology, costs, enrollment and group data.
- Working with or for a managed care organization.
- With oversight of a program; developing and administering special projects.
Basic level of proficiency in MS Excel, MS Word and industry claims platforms (including but not limited to Facets).
Knowledge of:
- State and federal laws and regulations pertaining to health insurance and/or government programs, including Medicare and/or Medicaid.
- CPT, ICD-10 and HCPCS codes.
- Statistics and data analytics techniques.
- HIPAA privacy and security rules.
Ability to request, use and analyze data to perform investigations.
Excellent verbal and written communication skills.

Invitations to interview will be based upon an assessment of education and experience. Applications will be forwarded to the hiring supervisor on an on-going basis. Posting will remain open until filled. Final candidates will be required to complete a background check.