Investigator

• Serve as the face of the Special Investigations Unit with external federal and state regulatory agencies
• Manage regulatory communications and ensure timely oversight-agency responses
• Identify and monitor emerging fraud, waste, and abuse trends
• Research claims, industry sources, and internal and external data to identify potential fraud
• Use data analytics platforms to mine large data volumes and identify fraudulent activity, patterns, and billing anomalies
• Develop and monitor the Annual Program Integrity Fraud, Waste and Abuse Plan
• Develop and implement innovative best practices aligned with growth and regulatory oversight
• Act as Program Integrity liaison with state and federal agencies
• Support deployment and monitoring of state-specific regulations for Medicaid and Medicare programs
• Build relationships through external fraud associations and industry partnerships
• Identify cost-avoidance opportunities through prepayment review, provider education, and preventive measures
• Ensure accuracy of regulatory reporting and respond to regulatory inquiries
• Ensure high-volume, quality FWA referrals to state partners
• Lead investigation on-sites and mentor the team
• Conduct and assist with complex investigations
• Collaborate with data analytics teams and use RAT-STATS for statistically valid random sampling
• Manage investigation turnaround times and case documentation quality
• Generate and trend fraud-detection leads to identify quality-improvement and focused-investigation opportunities
• Identify trends and patterns using corporate processes, tools, reports, databases, policies, coding guidelines, and regulations
• Manage and make decisions on claims pended for investigation
• Maintain knowledge of state and federal laws, rules, and provider billing guidelines
• Prepare and conduct in-depth complex interviews
• Execute and manage provider corrective action plans
• Participate in meetings with operational, business, legal, and regulatory partners
• Support legal actions, corrective actions, negotiations, recoveries, settlements, and evidentiary-document preparation
• Design data-analysis strategies for quality improvement and focused investigations
• Monitor media and state and federal press releases for emerging schemes and exposure
• Lead information-sharing activities and produce actionable data analyses
• Manage confidential investigative information
• Maintain compliance with laws, regulations, contracts, the Corporate Compliance Plan, and Anti-Fraud Plan
• Assist with federal and state regulatory audits
• Perform other job-related duties as requested

Explore Lead Investigator at CareSource. Review requirements and application details.