Investigator

• Receives, analyzes and coordinates fraud and abuse complaints from internal sources (customer services, claims processing, underwriting, professional affairs) and external sources (members, providers, state and federal regulatory agencies, law enforcement), then conducts and coordinates moderately complex investigations with expertise across various case types, participating in post-audit exit interviews where appropriate.
• Provides accurate accounting of recovered funds from audit activities, criminal or civil convictions and settlements, demonstrating continuing success in settlement, recovery and collection activities related to fraudulent activity.
• Maintains continuing education through anti-fraud and legal issue seminars, holds at least one professional credential (CPC, CPC-H or CPC-P), reviews pertinent articles and regulatory requirements, and provides post-audit education to providers to correct discrepancies, and trains new Investigators and other Cambia employees in detection of abusive or fraudulent billing practices.
• Assists with maintenance of audit and investigation files, formulation of company policies addressing loss exposures and solutions, and maintains extensive contact with the provider community in both educational and potentially confrontational or adversarial investigative roles.
• Issues audit findings and prepayment claim determinations, including maintaining clear documentation of the basis of findings and determinations, and maintaining the required professional judgment to support and deliver them independently.
• Represents company at external and internal meetings dealing with fraud and abuse issues and litigation proceedings, testifies in court as required, and develops professional working relationships with various associations and agencies for detection of local and national fraud and abuse schemes.
• Conducts witness and target interviews, identifying and analyzing evidence, examining records to verify document authenticity, preparing and evaluating investigation reports, providing information for affidavit preparation, and maintaining communications with law enforcement and regulatory agencies to present case findings for further investigation, prosecution or administrative remedies.

SIU Investigator conducting investigations into fraud and abuse allegations

Special Investigations Unit Investigator II – III

SIU Investigator conducting investigations into fraud and abuse allegations for Cambia Health Solutions. Perform audits and provide investigative support while educating others on fraud prevention.

• Administer the fraud, waste, and abuse (FWA) duties at an advanced level
• Ensure effective measures are in place and operating effectively to prevent, detect, and correct fraud, waste, and abuse
• Perform advanced level of fraud investigations and provide regular FWA reporting to regulatory agencies
• Help ensure that appropriate procedures are in place and followed consistently to safeguard assets, verify accuracy and reliability of data, and promote efficient operations
• Contribute to the development and operation of an effective FWA program in accordance with CMS requirements and Federal Sentencing Guidelines
• Prepare reports of audit findings and recommendations
• Educate and coach leaders and staff regarding FWA requirements and complex issues
• Participate in completing required Medicare and Medicaid filings and/or responses for FWA

Senior Investigator managing fraud, waste, and abuse responsibilities for CareOregon

Senior Investigator, Investigations Unit

Senior Investigator managing advanced FWA duties and investigations for CareOregon's health plan operations. Developing effective programs to prevent and rectify fraud, waste, and abuse issues.

• administer fraud, waste, and abuse (FWA) duties for CareOregon
• perform fraud investigations
• provide regular FWA reporting
• develop and operate an effective FWA program in accordance with CMS requirements
• perform routine FWA investigations, audits, and corrective actions
• prepare reports of audit findings
• respond to routine and ad hoc requests from external regulatory agencies
• prepare routine and ad hoc reports for internal and external leaders
• assist in developing and maintaining documentation system for FWA regulatory requirements
• review and recommend policy and procedure revisions
• attend internal and external FWA and compliance-related meetings
• assist in providing effective FWA training and education to staff
• educate providers on appropriate documentation and coding

Investigator managing fraud, waste, and abuse for CareOregon

Special Investigations Unit Investigator

Investigator managing fraud, waste, and abuse for CareOregon. Performing investigations, audits, and providing compliance reporting within a healthcare setting.

• Independently handles complex identity theft cases, primarily related to credit cards
• Reviews and analyzes customer intake and case information
• Conducts in-depth investigations
• Determines appropriate case direction or resolution
• Works closely with investigators, caseworkers, and leadership to ensure cases are thoroughly developed, accurately documented, and ready to move forward
• Supports quality and consistency across the investigation process

Credit Card Identity Theft Investigator at U.S. Bank handling complex identity theft cases.

Credit Card ID Theft Investigator

Credit Card Identity Theft Investigator at U.S. Bank handling complex identity theft cases primarily related to credit cards. Collaborating closely with investigators and caseworkers to ensure quality and consistency in the investigation process.

Investigator jobs in Oregon

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Special Investigations Unit Investigator II – III

Senior Investigator, Investigations Unit

Special Investigations Unit Investigator

Credit Card ID Theft Investigator