Investigator

🔥 15 hours ago

⚔️ Virginia – Remote

⚔️ Virginia – Remote

💵 $50k - $70k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

👻 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.

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Integrity Management Services, Inc.

WebsiteLinkedInAll Job Openings

51 - 200 employees

💼 Consulting

🏥 Healthcare

🛡️ Insurance

Consulting • Healthcare • Insurance

Integrity Management Services, Inc. is a women-owned, women-run company specializing in helping government and commercial enterprises minimize the risk of improper payments, fraud, waste, and abuse. The company provides a range of services including data analytics, fraud investigations, compliance reviews, audits, grants management, staff augmentation, and coding and medical reviews. IntegrityM, as they are known, works closely with Federal Government agencies, state agencies, and private sector organizations to drive informed decisions and enhance program transparency and oversight. The company is recognized for its contributions to the community and has been awarded for excellence in government contracting and corporate social responsibility.

📋 Description

• Perform high-level complex Medicare and Medicaid investigations and develop cases for future action, including law enforcement referrals, education, overpayment recovery, and other administrative actions • Conduct investigations into alleged healthcare fraud, waste, and abuse by researching offenses, reviewing records, performing interviews, and collecting evidence • Analyze investigative findings to determine whether allegations are substantiated and develop corrective actions or referrals with colleagues and subject matter experts • Develop, document, and maintain comprehensive case files and update databases and case tracking tools • Research Medicare and Medicaid claims data and other information to establish policy requirements • Prepare detailed investigative reports applying federal or state laws, rules, and regulations • Coordinate with internal teams and external agencies, including law enforcement, legal counsel, CMS, and state or federal investigators • Conduct background research on suspect providers to identify adverse relationships, sanctions, exclusions, or disqualifying information • Review and interpret healthcare policies, regulations, and instructions • Ensure evidence is collected, documented, and safeguarded according to rules of evidence and investigative guidelines • Analyze claims data to identify fraud, waste, and abuse patterns or anomalies and contribute to fraud scheme detection methodologies • Respond to law enforcement and client requests for data, documentation, or investigative support • Review and approve administrative action requests before submission to CMS and provide training and mentoring • Maintain statistics on submitted administrative actions and maintain template documents • Conduct on-site visits and in-person interviews when required

🎯 Requirements

• Bachelor degree in business or related field with 5-7 years experience (e.g., law enforcement investigation, statistics, data analysis) • 6+ years investigative experience in the Healthcare industry • At least 3 years of experience in benefit integrity investigation/detection or a related field demonstrating expertise in reviewing, analyzing/developing information, and making appropriate decisions • Knowledge of CMS Medicare Program Integrity Manual, Chapter 3 – Verifying Potential Errors and Taking Corrective Actions • Strong investigative skills • Advanced data analysis skills • Knowledge of medical terminology, ICD-9-CM, ICD-10-CM HCPCS level II and CPT codes • Utilizes Medicaid and Contractor guidelines for coverage determinations • Experience reviewing claims for appropriate billing and medical coding requirements, performing medical review, and/or developing fraud cases • Certified Fraud Examiner (CFE) or Accredited Health Care Fraud Investigator (AHFI) preferred • Must pass post hire background screening checks • For remote work, required to have wired and/or wireless internet access • Ability to obtain security clearance, if required by Client/Contract

🏖️ Benefits

• Vacation • Sick leave • Paid holidays • Health insurance • Dental insurance • Vision insurance • Short- and long-term disability • Life insurance • Employee assistance plan • 401(K) retirement plan • Educational benefits • Remote work • Wired and/or wireless internet access required for remote work