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    Associate Investigator, FWA-SIU - Boston, United States - Commonwealth Care Alliance

    Commonwealth Care Alliance
    Commonwealth Care Alliance Boston, United States

    2 days ago

    Default job background
    Description
    Why This Role is Important to Us

    The Associate Investigator works with a growing team conducting and managing Health Care Fraud, Waste and Abuse investigation and prevention activities under the general direction of the Director or designee.

    Supervision Exercised: No

    What You'll Be Doing
    • Plan, organize, and execute investigations or audits utilizing document review, witness interviews and data analysis to identify, evaluate and measure potential healthcare fraud and abuse to determine valid cases for appropriate action.
    • Document and track activity in internal database, provide case updates on progress of investigation, and coordinate with management recommendations and further actions and/or resolutions.
    • Prepare detailed reports on investigative findings for internal tracking, review and referral to Federal and State agencies as indicated.
    • Utilize data mining and visualization programs to design queries and analyze claims data to detect outliers or suspicious patterns for further investigation.
    • Conduct detailed research to identify and apply appropriate regulatory, contractual and industry requirements to the different benefits and products within investigations.
    • Proactively seek out and develop leads, resources and opportunities from a variety of sources, and develop and maintain relationships with enterprise, industry, law enforcement and other contacts.
    • Complete special projects and audits as required.
    • Understand and adhere to HIPAA privacy requirements.
    Working Conditions: Standard Office Conditions.

    What We're Looking For

    Education Required:
    • Bachelor's Degree or equivalent experience
    Experience Required:
    • At least three (3) years of related investigative, claims, compliance or analyst experience in healthcare, data reporting and/or data analysis required. Internships will be considered.
    • AHFI, CFE, CPC/medical coding, clinical background or formal data analyst background preferred.
    • Prior experience in health care compliance, regulation, SIU, government agency or similar position related to data analysis or an insurance-related field beneficial.
    • Proficiency in Microsoft Office (Word, Excel, PowerPoint, and Access) required.
    Knowledge, Skills Abilities Required:
    • Demonstrated understanding of common fraud schemes and ability to review and evaluate assigned referrals and apply appropriate investigative strategies needed.
    • Strong knowledge of standard industry coding guidelines such as CPT, HCPCS, ICD 10 and NCCI.
    • Ability to independently develop and present verbal and written investigative and management reports.
    • Knowledge of federal and state laws and regulations pertaining to fraud, waste and abuse.
    • Desire to work in a collaborative and fast-paced team environment.
    • Strong interpersonal, oral and written communication skills including presenting to internal and external stakeholders.
    • Ability to think creatively and approach this work to achieve corrective actions and process improvements.
    Language(s) Required:
    • English
    Other Required:
    • Standard office equipment
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