Senior Fraud, Waste and Abuse Investigator

Job not on LinkedIn

🔥 58 minutes ago

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

PacificSource Health Plans

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 1933

🏥 Healthcare

🛡️ Insurance

⚕️ Healthcare Insurance

Healthcare • Insurance • Healthcare Insurance

PacificSource Health Plans is a healthcare provider that offers a range of health insurance solutions, including plans for individuals, families, and employers. Their offerings include Medicare and Medicaid plans, dental coverage, and administrative services for small and large groups. Committed to member care, PacificSource emphasizes customer service and provides various resources for health management, including mental health support and wellness programs.

📋 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. • Serve as an internal Subject Matter Expert (SME) on matters related to auditing and FWA. • Develop and conduct internal FWA related training. • Collaborate with government agencies during audits, investigations and Requests for Information (RFI). • Present and discuss case findings and recommendations in case review meetings with department and company management. • Participate in the development and presentation of FWA reporting for the Corporate Compliance Committee and the Audit and Compliance Committee of the Board. • Coordinate and manage the production of investigative materials in support of settlement negotiations.

🎯 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. • Candidates with an associate’s degree and 2 years of relevant experience, or a high school diploma and 4 years of relevant experience, in addition to the required minimum years of work experience will also be considered. • 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 is required. • Working knowledge of legal and medical terminology.

🏖️ Benefits

• Flexible telecommute policy • medical, vision, and dental insurance • incentive program • paid time off and holidays • 401(k) plan • volunteer opportunities • tuition reimbursement and training • life insurance • options such as a flexible spending account