Investigator

• Prevent, detect, and deter fraud, waste, and abuse involving Commercial, Government, FEP, Medicare, and Part D programs
• Support Special Investigations Unit day-to-day operations, including investigations, analysis, management, and special projects
• Triage referrals and assess appropriate disposition
• Research and investigate allegations of fraud, waste, and abuse
• Use claims-processing systems, medical coverage guidelines, payment policies, benefits, and provider contracts
• Apply data-mining techniques, statistical data analysis, and analytical software to identify potential fraud, waste, and abuse
• Develop leads and cases from fraud alerts and government and private sources
• Prepare summary reports, corrective action plans, and investigative findings
• Escalate high-risk tips, cases, and related issues to management
• Conduct desktop and on-site medical-record audits, surveillance, undercover work, and suspect and witness interviews
• Prepare cases for referral to law-enforcement officials
• Testify and provide depositions as an expert witness
• Maintain chain of custody and document every stage of investigations
• Create, update, and follow operating procedures, policies, confidentiality requirements, and security guidelines
• Develop materials and assist with fraud, waste, and abuse training
• Attend annual seminars and webinars and participate in corporate task teams
• At higher levels, conduct complex investigations, develop queries, evaluate data integrity, provide technical guidance, manage case-tracking systems, design trend-analysis reports, support reporting requirements, coordinate external post-payment claims reviews, and perform quality audits

SIU Investigator I

• Conduct comprehensive reviews of medical records and documents supporting claims for providers, suppliers, pharmacies, and various healthcare services
• Provide investigative support to the Special Investigations Unit related to coding and billing issues
• Identify potential overpayments and suspected healthcare fraud and abuse
• Verify service authorizations and written documentation against claim information
• Ensure diagnosis and procedure codes supporting claims are appropriate and accurate
• Coordinate medical necessity and level-of-care determinations with Medical Directors
• Validate services against CMS and state-specific coverage, limitation, and exclusion guidelines
• Coordinate with internal and external resources to determine code appropriateness in administrative, medical, claim, and financial records
• Develop reports of findings and recommendations
• Communicate complex audit findings in meetings and/or judicial hearings
• Assist SIU investigators during interviews, discussions, and negotiations with providers, suppliers, and pharmacies
• Perform retrospective and prepayment medical-record reviews to identify fraud, waste, abuse, and inappropriate billing practices
• Investigate and analyze provider billing patterns to determine payment based on records, claims, codes, regulations, guidelines, and policies
• Prepare summaries of findings and recommend next steps for providers
• Identify preventive measures and recommend policy, procedure, and/or provider-practice changes
• Collaborate with investigators to identify abuse and fraud using clinical and coding expertise
• Perform other duties as assigned
• Comply with all policies and standards

Investigator jobs in Arizona

SIU Investigator I

Clinical Investigator, Behavioral Health