About the Role
This role is responsible for managing investigations related to fraudulent activity, improper billing, and misuse of healthcare resources. The position ensures adherence to regulatory standards and supports the protection of program integrity through proactive monitoring, team leadership, and strategic oversight.
Work Arrangement
On-site
Team
A collaborative team composed of leaders from multiple disciplines working together to achieve shared objectives.
Responsibilities
- Direct and supervise investigations into suspected fraud, waste, and abuse cases.
- Ensure compliance with federal and state healthcare regulations.
- Develop and maintain investigation protocols and standard operating procedures.
- Collaborate with legal, compliance, and audit teams to resolve complex cases.
- Oversee case documentation and reporting to ensure accuracy and completeness.
- Lead root cause analysis to identify systemic vulnerabilities.
- Provide regular updates to senior management on investigation status and trends.
- Train staff on fraud detection techniques and regulatory requirements.
- Evaluate data patterns to detect potential anomalies and risks.
- Coordinate with external agencies when necessary for case resolution.
- Maintain confidentiality and integrity of sensitive investigative information.
- Support internal audits and regulatory examinations.
- Implement corrective actions based on investigation findings.
- Monitor post-resolution outcomes to assess effectiveness of interventions.
- Ensure timely closure of cases in accordance with policy timelines.
- Develop performance metrics for investigation team productivity.
- Promote a culture of compliance across departments.
- Respond to inquiries from oversight bodies or regulatory entities.
- Assist in the development of fraud prevention strategies.
- Evaluate new technologies or tools to enhance investigative capabilities.
- Facilitate communication between departments involved in case resolution.
- Ensure adherence to internal control frameworks.
- Manage relationships with third-party vendors involved in fraud detection.
- Prepare executive-level summaries of key investigations.
- Support policy updates based on emerging fraud trends.
Qualifications
- Bachelor's degree in criminal justice, healthcare administration, or related field.
- Minimum of five years of investigative experience in healthcare fraud.
- Proven knowledge of healthcare compliance laws and regulations.
- Experience managing teams in a compliance or investigative setting.
- Strong understanding of medical billing and coding practices.
- Familiarity with Medicare and Medicaid program requirements.
- Proficiency in using data analysis tools for fraud detection.
- Certification such as CFE or CHC is highly preferred.
- Excellent written and verbal communication skills.
- Ability to interpret complex regulatory guidance.
- Experience with case management software systems.
- Solid judgment in handling sensitive and confidential matters.
- Project management skills with attention to detail.
- Experience conducting interviews and gathering evidence.
- Knowledge of audit processes and regulatory reporting.
- Ability to work independently and lead initiatives.
- Strong ethical standards and professional integrity.
- Experience in a managed care or pharmacy benefit environment.
- Understanding of data privacy laws such as HIPAA.
- Track record of successful investigation resolutions.
- Skilled in preparing reports for regulatory submissions.
- Background in law enforcement or federal investigations a plus.
- Experience with risk assessment frameworks.
- Ability to adapt to evolving compliance landscapes.
- Demonstrated ability to influence cross-functional teams.
Physical Requirements
- Sedentary work involving prolonged periods at a desk and computer use.
- Occasional lifting of up to 10 pounds, such as files or office supplies.
- Regular use of keyboard, mouse, and standard office equipment.
- Ability to remain seated for extended durations.
- Frequent reading and reviewing electronic or printed documents.
- Typing and data entry for investigative records and reports.
- Attending meetings in person or via video conferencing.
- Minimal travel may be required for training or coordination.
- Work performed in a climate-controlled office environment.
- Consistent attendance during core business hours.
