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GENERAL SUMMARY OF POSITION: 

Under the general direction of the Associate Director, or designee, the Investigator I serves a crucial role in combating fraud, waste and abuse (FWA) within the Medicaid program.  Investigations involve extensive research to identify industry trends and patterns which target aberrant billing practices.  The Investigator I collaborates with the Associate Director on case reviews in addition to performing activities related to data mining, data analysis and recoveries.

MAJOR RESPONSIBILITIES:

• Conduct with assistance data mining and data analysis utilizing claims data to detect aberrancies and outliers in claims and develop trends and patterns for potential cases
• Develop with assistance audit rules, queries and reports to detect potential FWA activity.
• Analyze member records and claims data to ensure compliance with applicable     regulations, contracts and policy manuals.
• Develop reports of investigative findings, compile case file documentation, calculate overpayments, and issue findings in accordance with agency policies and procedures.
• Document work performed and audit results based on pre-determined standards and guidelines.
• Communicate with providers routinely regarding issues including audit findings, recoveries and educational feedback.
• Identify and recommend policy, procedure and system changes to enhance investigative outcomes and performance based on findings with assistance
• Serve as a resource for departments to research and resolve integrity inquiries.
• Update appropriate internal management staff regularly on progress of investigations and make recommendations for further initiatives such as new algorithms.
• Collaborate with Associate Director on cases to ensure proper analysis and data mining is performed.
• Assist in the preparation of internal and external reports for tracking of cases and summary information.
• Create, maintain and manage cases within the tracking system to ensure information is accurate and timely.
• Perform other duties as required

REQUIRED QUALIFICATIONS:

• A Bachelors’ degree in Business Administration, finance ore related field; or equivalent years of experience.
• A minimum of 4 years of related experience in fraud examination, healthcare, business, accounting or finance.
• Previous experience conducting data mining in the healthcare insurance industry and claims related experience.
• Knowledge of coding, reimbursement and claims processing policies.
• Knowledge of the principles and practices of medical auditing.
• Strong analytical and qualitative skills as well as problem solving skills with the ability to look for root causes and implement workable solutions.
• Knowledge of the law and regulations as it relates to fraud and fraud investigations.
• Must have a track record of producing high quality work that demonstrates attention to detail.
• Ability to multi-task, establish priorities and work independently to achieve objectives.
• Ability to function effectively under pressure.
• Proficient in Microsoft Office applications (Word, Excel, PowerPoint and Access).
• Excellent customer service skills with the ability to interact professionally and effectively with providers, third party payers, and staff from all departments.
• Strong interpersonal skills with the ability to work in a fast paced environment whether as a team member or an independent contributor
• Strong oral and written communication skills including internal and external presentations.

PREFERRED QUALIFICATIONS:

• Master’s degree in Business Administration or Public Health.
• Prefer individual possessing any of the following certifications or licensure: CFE, CPA, RN/LPN, CPC, or CPMA. 
• Advanced Microsoft Excel software skills.
• Knowledge of State and Federal regulations as they apply to public assistance programs.
• Strong Decision making skills with the ability to investigate and weigh alternatives and select the appropriate course of action.
• Creative thinking skills with the ability to ask the needed “bigger- picture” questions that lead to process and team improvements