Senior Fraud, Waste and Abuse Investigator

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🔥 57 minutes ago

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PACIFICSOURCE

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 1933

Not-for-profit health plans

📋 Description

• Independently plan, conduct, and manage prompt, thorough onsite and desk-top investigations of health care claims. • Thoroughly document investigative findings and actions to create comprehensive case files in accordance with established policies and procedures. • Proactively utilize available analytic resources to identify patterns of potential Fraud, Waste and Abuse, initiating audits when necessary. • Conduct fact-finding interviews with internal staff, external providers, patients and other relevant parties regarding medical and behavioral health services initiating investigations when necessary. • Utilize available Open Source Intelligence (OSINT) tools to verify provider licenses, research criminal history, disciplinary actions, financial assets and liabilities. • Attend and participate in regional FWA Task Force and other state or federal meetings. • Establish and maintain a comprehensive knowledge and understanding of current state and federal reporting requirements ensuring FWA reporting is received, summarized, catalogued, and disseminated to the appropriate agencies. • Ensure regulatory reporting is developed, accurate, and submitted timely.

🎯 Requirements

• Minimum of 5 years of experience with complex healthcare fraud investigations required. • Experience facilitating audit activities across specialized teams required. • Experience navigating case management, claims and OSINT platforms preferred. • Bachelor's degree in business administration, criminal justice, or related field required. • Ability to obtain Certified Fraud Examiner (CFE) or equivalent certification within 24 months of employment required. • Strong working knowledge of investigative techniques and procedures as they relate to health care fraud, waste and abuse.

🏖️ Benefits

• Health insurance • Retirement plans • Paid time off • Flexible work arrangements • Professional development