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Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates extensive investigative experience with a strong focus on fraud detection, case development, and regulatory compliance. Capable of mentoring teams, managing workloads, and ensuring quality control in investigations while effectively communicating with various stakeholders.
Highest-signal resume keywords
Investigative ExperienceFraud DetectionRegulatory ComplianceLeadership SkillsCommunication Skills
About the role
Key responsibilities & impact- Achieve quality objectives and oversee workload to promote timely development and resolution of investigations
- Develop cases for referral to law enforcement or other entities
- Provide mentoring and guidance to the investigative team
- Act as a point of contact for the manager
- Assist team members with referral background, analysis, and workflow development
- Review individual workload during monthly meetings, assist with prioritization, and conduct quality control for staff
- Monitor the quality of UCM/WMM
- Monitor timeliness for case updates and prioritize referrals and complaints as leads and investigations as necessary
- Monitor complaint and referral progress to ensure use of available remedies, transfer to field investigations, and recommend further review
- Mentor team members in identifying previously undetected fraud, waste, or abuse through proactive or reactive research, analysis, and development
Requirements
What you’ll need- 8 years with a BS/BA or 12 years of experience with a HS Diploma
- At least 5 years of relevant investigative experience required
- Strong communication and organization skills
- Strong leadership background
- Strong PC knowledge and skills
- U.S. citizenship required
- Knowledge of Medicare requirements, laws, rules and regulations related to payment for services billed the Program
- Experience in developing leads and investigations, conducting detailed background and link analysis, reviewing claims data, performing medical review, and/or developing fraud cases
- Ability to perform research and draw conclusions
- Ability to present issues of concern, citing regulatory violations, alleging schemes or scams to defraud the Government
- Ability to organize a case file and accurately and thoroughly document all steps taken
- Ability to compose correspondence, reports and referral summary letters
- Ability to educate providers, provider associations, law enforcement, other contractors and beneficiary advocacy groups on program safeguard matters
- Ability to communicate effectively, internally and externally
- Ability to mentor and train others
- Ability to interpret laws and regulations
- Ability to handle confidential material
- Ability to report work activity on a timely basis
- Ability to work independently and as a member of a team to deliver high quality work
- Ability to attend meetings, training, and conferences; overnight travel required
- Ability to document QC results in WMM according to record type
Benefits
Comp & perks- Telework available from AL, FL, GA, NC, SC, TN, VA, WV
- Employees may be eligible for overtime, shift differential, and a discretionary bonus in addition to base pay
ATS Keywords
✓ Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Case DevelopmentBackground AnalysisLink AnalysisClaims Data ReviewMedical ReviewFraud Case DevelopmentResearch SkillsDocumentation SkillsQuality ControlTimeliness Monitoring
Soft Skills
MentoringOrganizational SkillsTeam CollaborationEffective CommunicationTraining Others
Tools & Technologies
UCMWMMPC Knowledge
Industry Keywords
Medicare RequirementsLaws and RegulationsFraudWasteAbuseProgram Safeguard Matters