Job Brief

This position is remote eligible but will have site visits in New Hampshire

The Investigator is responsible for conducting comprehensive investigations of reported, alleged or suspected fraud involving the full range of products at the AmeriHealth Caritas Family of Companies (ACFC).

Major Accountabilities:

• Ensures compliance with all requirements related to Special Investigation Units and fraud, waste and abuse investigations.
• Conducts investigations of potential fraud, waste and/or abuse with a focus on thoroughness and attention to detail, quality, timeliness and cost control.
• Conducts comprehensive interviews with providers, members and witnesses to obtain information which would be considered admissible under generally accepted criminal and civil rules of evidence.
• Proactively performs research using the Internet, data analysis tools, etc., to analyze aberrant claims billing and practice patterns.
• Analyzes data as part of the investigative process using available fraud detection software and corporate resources.
• Represents ACFC in conducting settlement negotiations with providers, counsel and/or other associated parties.
• Prepares and submits investigative reports covering all phases of the investigation.
• Interprets and conveys highly technical information to others.
• Establishes and maintains liaison with public officials, law enforcement and others to obtain assistance in conducting investigations.

Education/ Experience:

• Associate's degree required; Bachelor’s Degree preferred.
• Valid driver’s license required
• Experience with LTSS preferred
• Ability to work independently with minimal supervision, and manage a high volume of assignments.
• Strong verbal and written communication skills.
• High degree of integrity and confidentiality required handling information that is considered personal and confidential.
• Analytical skills and ability to make deductions; logical and sequential thinker.
• A minimum of 3-5 years experience conducting comprehensive health care fraud investigations; interacting with state, federal and local law enforcement agencies.

Other Skills:

• Health care industry and/or Medicare/Medicaid/Pharmacy/Behavioral Health/Pharmacy Benefit Management knowledge required.
• Law enforcement experience preferred.
• Clinical Experience preferred
• SIU and/or State Medicaid regulatory compliance work experience preferred.
• Knowledge and proficiency in claims adjudication standards & procedures preferred.
• Solid knowledge of Medicaid, Medicare, and pharmacy benefit laws and requirements; federal, state, civil and criminal statutes.
• Experience with decision support tools used for data analysis.
• Advanced knowledge and experience working on various approaches to fraud, waste and abuse.
• Working knowledge of Microsoft applications, especially Excel required.
• Knowledge of available resources (internal and external) to assist in investigations.