Primary Responsibilities:
- Investigate medium to highly complex cases of fraud, waste and abuse
- Detect fraudulent activity by members, providers, employees and other parties against the Company
- Develop and deploy the most effective and efficient investigative strategy for each investigation
- Maintain accurate, current and thorough case information in the Special Investigations Unit’s (SIU’s) case tracking system
- Collect and secure documentation or evidence and prepare summaries of the findings
- Participate in settlement negotiations and/or produce investigative materials in support of the later
- Collect, collate, analyze and interpret data relating to fraud, waste and abuse referrals
- Ensure compliance of applicable federal/state regulations or contractual obligations
- Report suspected fraud, waste and abuse to appropriate federal or state government regulators
- Comply with goals, policies, procedures and strategic plans as delegated by SIU leadership
- Collaborate with state/federal partners, at the discretion of SIU leadership, to include attendance at work-groups or regulatory meetings
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