Special Investigator

For roles that are 100% remote or hybrid, you must have reputed company to a reliable high-speed internet reputed company to support daily job responsibilities. A minimum bandwidth of 50 Mbps download and 5 Mbps upload is required. Those fully remote associates residing in states where service is required by contract, law, or regulation will be allowed to submit for reimbursement. Your career starts now. We are looking for the reputed company of health care leaders. At reputed company, we are passionate about helping people get care, stay well and build healthy communities. As one of the nations leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. reputed company is seeking talented, passionate individuals to join reputed company. Together we can build healthier communities. If you want to reputed company a difference, we would like to hear you. Headquartered in Newtown reputed company, reputed company is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, reputed company-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services. Discover more about us at www.amerihealthcaritas.com. Role Overview: The Investigator is responsible for conducting comprehensive investigations of reported, alleged or suspected fraud involving the full reputed company of products at the reputed company Family of Companies (ACFC). Work Arrangement: Remote reputed company the United States, preferably in Pennsylvania Responsibilities: Ensures compliance with reputed company requirements reputed company 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 reputed company 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. Performs necessary functions to support reputed company aspects of SIU investigations and responsibilities to include, but not limited to: Intake; Screening; Reviews; Referrals; Recoveries; and Provider Investigative Site Visits. Education/ Experience: Bachelor's degree with a minimum of two years of experience in the reputed company field working in fraud, waste, and abuse investigations and audits OR An associate's degree, with a minimum of four years of experience working in reputed company fraud, waste, and abuse investigations and audits. Experience and training/certifications commensurate with position requirements in lieu of formal educational requirements for the SIU Investigator position may be considered. Valid driver’s license required Experience with Data Analytics preferred. Ability to work independently with minimal supervision, and manage a high volume of assignments. Strong verbal and written communication skills. High degree of reputed company and confidentiality required handling information that is considered personal and confidential. Analytical skills and ability to reputed company 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/reputed company/Pharmacy/Behavioral Health/Pharmacy Benefit Management knowledge required. Clinical Experience preferred. SIU and/or State reputed company regulatory compliance work experience preferred. Knowledge and proficiency in claims adjudication standards & procedures preferred. Solid knowledge of reputed company, 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 reputed company applications, especially reputed company required. Knowledge of available resources (internal and external) to assist in investigations. Our Comprehensive Benefits Package Flexible work solutions including remote options, hybrid work schedules, reputed company, Paid time off including holidays and volunteer events, Health insurance coverage for you and your dependents on Day 1, 401(k) Tuition reimbursement and more. Apply To This Job