Investigator I

HMSA is seeking an Investigator I for their Special Investigations Unit. The role involves managing fraud, waste, and abuse allegations, conducting investigations, and coordinating with various entities to resolve cases.

Responsibilities

• Manage FWA case investigations, collaborate with federal, state and law enforcement entities, and provide applicable notifications as required
• Maintain extensive documentation and evidence for SIU cases
• Recommend and implement preventive measures to combat FWA schemes including, but not limited to provider education, policies, claims edits and payment suspensions
• Manage the recovery, allocation and documentation of health plan funds resulting from FWA findings
• Manage the intake, documentation and resolution of FWA referrals to SIU
• Coordinate with internal and external partners on FWA allegations
• Assess needs, make recommendations and complete timely reviews in accordance with all regulatory requirements
• Create and maintain internal policies and procedures, workflows and presentations and present as needed to internal and external entities
• Support regulatory audits and RFIs from law enforcement and federal and state entities
• Represent SIU at cross functional workgroups and meetings and present case recommendations to other applicable business areas including, but not limited to Legal, Medical Management, Provider Operations and Claims Administration
• Perform all other miscellaneous responsibilities and duties as assigned or directed

Skills

• Bachelor's degree and one (1) year of related work experience; or equivalent combination of education and related work experience
• Fundamental knowledge/awareness of Fraud, Waste and Abuse
• Strong oral and written communication skills
• Basic working knowledge of Microsoft Word, Excel, and PowerPoint
• Intermediate working knowledge of Microsoft Outlook

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