Senior Investigator

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🔥 1 hour ago

🐊 Florida – Remote

🐊 Florida – Remote

💵 $65.3k - $111k / year

⏰ Full Time

🟠 Senior

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PacificSource Health Plans

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 1933

⚕️ Healthcare Insurance

💸 Finance

🧘 Wellness

Healthcare Insurance • Finance • Wellness

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 4 years of experience conducting complex healthcare fraud investigations required. • Significant experience in facilitating audit activities across specialized teams required. • Ability to effectively and professionally communicate with internal and external stakeholders, in both written and verbal form, required. • Ability to independently research, understand and interpret complex healthcare claims data, civil and criminal laws, and contract requirements required. • Experience in navigating case management, claims and OSINT platforms preferred. • Bachelor’s degree in business administration, criminal justice, or related field or a combination of equivalent education and experience is required. • Ability to obtain Certified Fraud Examiner (CFE) or equivalent certification within 24 months of employment required.

🏖️ 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