Healthcare Fraud Investigator (Full-time, Remote)

Integrity Management Services, Inc. (IntegrityM) is a woman-owned small business specializing in assisting government healthcare organizations prevent and detect fraud and abuse in their programs.

At IntegrityM, we offer a culture of opportunity, recognition, and collaboration. We thrive off of these fundamental elements that make IntegrityM a great place to work. We offer the flexibility our employees need to challenge themselves and focus on advancing their professional development and careers. Large company perks. Small company feel.

http://www.integritym.com

IntegrityM is proud to be named to the 2024 Top Workplaces list by The Washington Post! Our leaders inspire and empower each team member to break boundaries and lead with integrity. We foster a diverse community with flexible, remote-friendly career paths that nurture growth and fulfillment.

In this role, the Investigator will use a variety of tools to initiate investigations, identify subjects and develop cases for future action, including a referral to law enforcement, education, over payment recovery and other administrative actions meeting all applicable client requirements. The Investigator works independently as well as collaboratively with various team members and managers.

Job Responsibilities:

• Maintains strict confidentiality and security of all sensitive and/or business confidential information obtained or accessed during the course of business and/or contract operations.

• Adheres to all IntegrityM and/or client privacy and security protocols governing sensitive and/or business confidential information.

• Ensures compliance with all applicable privacy and security training requirements (both IntegrityM and external/client-based), whether on an annual or ad/hoc basis. Please note: certain position levels (leads, managers, directors or higher) may require additional “role-based” training to ensure compliance with applicable privacy and security requirements.

• Conducts data analysis of claims data to identify instances of suspected healthcare fraud, waste, and abuse in Medicare Part C and Part D benefits.

• Conducts background research of suspect providers to identify information regarding adverse business relationships, disqualifying violations, exclusions or licensing sanctions.

• Reviews policies, regulations and instructions relevant to supporting suspected healthcare fraud, waste and abuse violations and provides that information as necessary in support of data analysis findings.

• Documents all findings relevant to support recommendations for further analysis or investigation referrals.

• Collects and reviews records and documents relevant to investigation development.

• Conducts interviews and maintains accountability and safeguards any items considered to be of evidentiary value in accordance with established guidelines and rules of evidence.

• Coordinates investigations with appropriate federal and state law enforcement agencies, legal counsel and state and federal program administration agencies.

• Testifies at various legal proceedings as necessary.

• Coordinates with medical reviewers, data analysts, program managers, SMEs, and other staff as appropriate to develop or unfound investigations.

• Inputs data into appropriate database tracking programs as needed in accordance with established rules.

• Coordinates with clients in support of findings and recommendations resulting from investigations and data analysis.

• Provides input into development of new fraud scheme studies.

• Identifies opportunities to improve processes and procedures.

• Meets all established deadlines.

• Works with internal resources and external agencies to develop cases and corrective actions, as well as responds to requests for data and support.

• Maintains fraud case development quality standards so that proper case development is ensured, and quality cases are fully prepared.

• Maintains proper and timely updates in appropriate tools and applications for their investigations. Case development databases and documents.

• Completes all requests for information from law enforcement within required timeframes.

• Improves client processes so that efficiencies are achieved to complete a task and ISO 9001:2008 related activities are completed.

• Enhances fraud detection and improves interdepartmental workflow so that it is evident the client is being proactive in its efforts to identify potentially fraudulent schemes.

• Conducts on-site visits and/or interviews as required for investigation.

• Performs ad hoc tasks/duties as assigned.

• Maintains a professional appearance, workplace demeanor and work schedule compliance.

• Ability to grasp and adapt to changes in procedure and process.

• Exercises appropriate discretion and independent judgment relating to company policies and practices in an effective, consistent and professional manner.

• Adheres to applicable policies and procedures ensuring commitment to quality, compliance and security protect the confidentiality, integrity, and availability of sensitive data and information. 

Requirements

• High school diploma required, Bachelors degree preferred (e.g., law enforcement investigation, statistics, data analysis)
• Three to five years’ experience in healthcare fraud investigation/detection.
• Medicare and Medicaid investigative experience preferred (e.g., Part C, Part D, DME, Home Health and Hospice)
• Strong investigative, analytical and problem-solving skills
• Strong communication and organization skills
• Experience in reviewing claims for technical requirements, performing medical review, and/or developing fraud cases
• Strong PC knowledge and skills
• Certified Fraud Examiner (CFE) or Accredited Health Care Fraud Investigator (AHFI) preferred

Additional Requirements:

• Must pass post hire background screening checks.