Investigator

Amerihealth Caritas Health Plan Philadelphia , PA 19107

Posted 6 days ago

Responsibilities:

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).

Seeking part-time, 20 hours/week.

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 ACFCin 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 or equivalent work experience.

  • Accredited Health Care Fraud Examiner (AHFI) preferred.

  • Certified Insurance Fraud Investigator (CIFI) preferred.

  • Fraud Claim Law Specialist (FCLS) preferred.

  • Certified Fraud Examiner (CFE) preferred.

  • Valid driver's license required.

  • 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 years experience conducting comprehensive insurance investigations; interacting with state, federal and local law enforcement agencies.

  • Law enforcement experience preferred.

  • SIU and/or State Medicaid regulatory compliance work experience a plus.

  • Knowledge andproficiency in claims adjudication standards & procedures preferred.

  • Experience with Medicaid, Medicare, and/or pharmacy benefit reimbursement.Specific experience required driven by business needs.

  • 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.

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Investigator

Amerihealth Caritas Health Plan