Junior Investigator, Program Integrity

Job not on LinkedIn

🔥 15 hours ago

🇺🇸 United States – Remote

💵 $50k / year

⏰ Full Time

🟢 Junior

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

👻 Ghost score 0%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

Apply Now

Find Similar Remote Jobs

Set Up Email Alert For New Jobs

📊 Check your resume score for this job

Improve your chances of getting an interview by checking your resume score before you apply.

Upload Resume

Evolent

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

⚕️ Healthcare Insurance

🏥 Healthcare

☁️ SaaS

Healthcare Insurance • Healthcare • SaaS

Evolent is a healthcare company focused on improving care outcomes through its comprehensive management solutions across multiple medical specialties. They aim to enhance the patient care journey by offering coordinated services in areas like oncology, cardiology, musculoskeletal disorders, and primary care, while ensuring high-quality treatment pathways and cost management. Evolent believes every person deserves quality care, striving to align treatment guidelines and innovative approaches to meet patient needs effectively.

📋 Description

• Perform preliminary research using internal and external databases to identify potential indicators of Fraud, Waste, and Abuse • Assist investigators in developing and progressing investigations • Gather, compile, and organize investigative information from multiple data sources • Identify potential investigative leads and trends from HFPP memoranda, referrals, and other sources • Conduct preliminary reviews of provider, member, and claims information • Gather and review data in response to Special Investigations Unit inquiries • Retrieve and review claims data using claims and analytical databases • Review claims, utilization, and payment data for aberrancies, patterns, trends, and anomalies • Assist in analyzing data to support investigative findings and recommendations • Prepare summaries of research findings and investigative observations • Document investigative activities, findings, and case updates in the SIU case management system • Maintain accurate, complete, and timely case and referral records • Prepare correspondence and supporting documentation • Maintain notes and documentation on assigned projects • Distribute outbound correspondence to providers using approved electronic vendor platforms • Track provider responses and maintain communication records • Monitor and track workflow activities • Participate in SIU meetings and contribute to operational discussions and investigative planning • Maintain confidentiality of sensitive investigative, member, provider, and organizational information • Stay current on Fraud, Waste, and Abuse trends, regulations, and investigative best practices • Perform other duties, projects, and assignments as requested • Collaborate with SIU investigators, compliance personnel, legal teams, operational departments, network management teams, and external partners

🎯 Requirements

• One (1) to three (3) years of experience in healthcare operations, claims analysis, fraud detection, compliance, auditing, investigations, data analysis, or a related field preferred • Experience working with healthcare claims, provider data, or medical records • Basic understanding of healthcare fraud, waste, and abuse concepts • Bachelor's degree in criminal justice, Healthcare Administration, Business Administration, Finance, Health Information Management, or a related field; or equivalent combination of education and experience • Experience with healthcare claims processing, SIU operations, compliance, auditing, or investigative support • Experience using claims databases, data analytics tools, or case management systems • Certified Fraud Examiner (CFE), Accredited Healthcare Fraud Investigator (AHFI) • Strong analytical and critical thinking skills • Ability to identify trends, anomalies, and potential indicators of Fraud, Waste, and Abuse • Strong attention to detail and organizational skills • Ability to research information from multiple sources • Proficiency with Microsoft Office applications, particularly Excel, Word, and Outlook • Ability to learn and utilize investigative, claims, and case management systems • Effective written and verbal communication skills • Ability to maintain strict confidentiality and handle sensitive information appropriately • Ability to manage multiple assignments and meet established deadlines • High-speed internet over 10 Mbps at home

🏖️ Benefits

• Work/life balance • Flexibility to suit work to your life • Autonomy to get things done • Comprehensive benefits, including health insurance benefits, for qualifying employees • High-speed internet requirement for home work setup