Fraud Investigator Job Description
As the Fraud Investigator for AdvanceMed, a premier provider of healthcare program integrity services, you will perform in-depth evaluation and analysis of Medicare and Medicaid records. In this role, Fraud Investigator will research monetary losses, conduct independent investigations, utilize data analysis, and will be a critical component in meeting AdvanceMed’s mission “To provide services to our clients that exceed their expectations and contribute to improved healthcare delivery by identifying and eliminating fraud, waste, and abuse.”
Fraud Investigator Highlights of Responsiblities:
- Develop investigations that involve monetary losses, sensitive issues that may meet criteria for referral to law enforcement, or the imposition of administrative actions.
- Conduct independent investigations resulting from the discovery of situations that potentially involve fraud or abuse.
- Fraud Investigator Utilize data analysis techniques to detect aberrancies in Medicare claims data, and proactively seek out and develop leads received from a variety of sources
- Complete written referrals to law enforcement and takes steps to recoup overpaid monies.
- Fraud Investigator Review information contained in standard claims processing system files to determine provider billing patterns and to detect potential fraudulent or abusive billing practices or vulnerabilities in Medicare policies.
- Develop and prepare potential Fraud Alerts and Program Vulnerabilities for submission to CMS; share information on current fraud investigations with other Medicare contractors, law enforcement, and other applicable stakeholders.
- Fraud Investigator Review and respond to requests for information from Medicare stakeholders as assigned; pursues applicable administrative actions during investigation/case development (e.g. payment suspensions, civil monetary penalties, requests for exclusion, etc.).
Fraud Investigator Requirements
- High School Diploma
- Previous investigative or law enforcement experience or applicable healthcare knowledge
Fraud Investigator Preferred Education and Experience:
- Bachelor’s Degree or 5+ years of related experience
- Previous investigative or fraud detection experience within the Medicare Program.
- CFE (Certified Fraud Examiners) Designation
- Knowledge of statistics, data analysis techniques and ZPIC skills
Location: Nashville, TN
Security Clearance Status: Not Applicable
Security Clearance Type: Background Check
US Citizenship Required: No
Job Level: Individual Contributor
Employment Status: Full-Time
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