Special Investigator / Healthcare Fraud
Berkshire Hathaway Homestate Companies - San Francisco, CA

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BASIC FUNCTION:

The Special Investigator/Healthcare Fraud is responsible for the detection and investigation of fraudulent practices by medical providers and other vendors who bill the company for services and equipment provided in connection with workers’ compensation claims.

ESSENTIAL RESPONSIBILITIES:

• Assist the Director of Special Investigations in the development and operation of a comprehensive program for the prevention, detection, investigation, litigation, and prosecution of fraudulent practices by medical providers and other vendors.
• Attain and maintain the highest level of expertise regarding workers compensation provider fraud, investigative techniques, and legal requirements and limitations relating to investigations, including new developments and current trends in those areas.
• Identify and analyze patterns and trends in the fraudulent activities of medical providers and other vendors throughout the United States.
• Conduct effective investigations into suspected fraud by medical providers and other vendors, generating evidence that can be used to limit the company’s losses, control claim costs, and support criminal prosecutions.
• Develop and employ sophisticated research techniques to identify investigative leads and information through the use of electronic databases, public records, social media, company data, and other sources of information.
• Direct and evaluate the work of outside investigators retained to provide investigative assistance to the company.
• Prepare clear, detailed reports and presentations regarding investigative methods, objectives, findings, and recommendations accompanied by realistic assessments of the company’s legal and financial exposure in a variety of circumstances.
• Coordinate with other members of the Special Investigations Unit and with key internal partners – including Medical Bill Review, Utilization Review, Resolution, Adjusting, and Legal – to share information and expertise, define investigative strategies and goals, and make maximum effective use of investigative results to protect the interests of the company.
• Coordinate with in-house and outside counsel in the investigation, litigation, negotiation, and/or settlement of disputes with medical providers and other vendors suspected of defrauding the company.
• Continually expand the Special Investigations Unit’s network of contacts and sources of information in the medical, legal, academic, insurance, and law-enforcement communities throughout the United States.
• Comply with company policies and statutory and regulatory requirements regarding investigative methods, practices, training, and reporting in each state. Assist in the preparation and submission of reports documenting compliance with all such requirements.
• Prepare and submit documented referrals of provider and vendor fraud to regulatory, prosecutorial, and law-enforcement authorities for potential disciplinary, civil, and criminal action. Respond promptly to requests for information from such authorities.
• Assist in the creation and presentation of anti-fraud training programs and materials to company employees.
• Serve as a role model for the company’s culture by embodying the highest standards of collaboration, performance, professional conduct, and ethical standards.

QUALIFICATIONS:

• Education/Experience: Bachelor’s degree from an accredited college or university with at least three years of experience in an analytical or investigative role relating to health care, workers’ compensation insurance, and/or related field. A degree in criminal justice or a similar field is preferred but not required.
• Language and Technical Skills: Able to read, analyze, and interpret medical reports and invoices, statutes, regulations, contracts, financial reports, and legal documents. Able to understand medical and legal terminology. Able to respond effectively to technical inquiries or complaints from company employees, external sources, and regulatory or auditing entities. Able to effectively present information and respond to questions when interacting with managers, clients, claimants, attorneys, medical providers, vendors, witnesses, and others. Able to formulate effective questions and elicit pertinent facts from people of all ages and backgrounds. Able to write clear, effective correspondence on complex issues. Proficiency in spoken Spanish is advantageous but not required.
• Math Ability: Able to identify patterns, anomalies, or inconsistencies in sets of data that may indicate the presence of issues requiring investigation. Able to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Able to compute rate, ratio, and percent.
• Reasoning Ability: Able to apply common-sense understanding to carry out instructions furnished in written, oral, or diagram form. Able to deal with problems involving several concrete variables in standardized situations.
• Computer Skills: Strong grasp of Microsoft Office software, including Excel and PowerPoint. Able to quickly master proprietary and vended software applications.

COMPREHENSIVE BENEFITS PACKAGE:

• Health
• Dental
• Vision
• Life
• Disability and AD&D
• Retirement & Savings Plan with 100% employer match up to 5% of salary
• Education Assistance Reimbursement
• Paid Vacation and Holidays

ABOUT US:

Berkshire Hathaway Homestate Companies, a nationwide family of insurance carriers, is accepting applications from talented and highly motivated candidates to fill an existing opening for a healthcare fraud investigator specializing in the detection and investigation of unscrupulous healthcare providers and vendors. This is a rare opportunity to have a significant and lasting impact on the success of a company widely recognized for its financial strength and commitment to excellence. The healthcare fraud investigator will join a fast-growing department dedicated to protecting the company, its beneficiaries, and the workers compensation system itself against fraudulent practices by doctors, attorneys, hospitals, clinics, laboratories, medical equipment providers, transportation services, interpreters, and other providers of services to workers compensation claimants. The successful candidate will combine strong academics and computer skills with at least three years of practical experience in an analytical or investigative role involving health care, workers compensation insurance, and/or related field. Strongly preferred are candidates with an in-depth knowledge of the health care industry, including medical terminology, billing codes, and medical reporting, as well as a demonstrated ability to mine, organize and interpret large volumes of data to recognize patterns, spot trends, and identify fraudulent practices. Experience in field investigations, including interview and evidence-gathering techniques, and experience with litigation strategy are all advantageous, as are an abiding commitment to the truth, an appetite for exposing wrongs, and a keen understanding the social and financial consequences of fraud.

The Berkshire Hathaway Homestate Companies (BHHC) is a group of six insurance companies that are part of the Berkshire Hathaway Insurance Group, headquartered in Omaha, Nebraska. Our Workers Compensation Division provides premier workers compensation insurance coverage to employers across the country, with offices in San Francisco, San Diego, Pasadena, Omaha, St. Louis, Atlanta, and Dallas.

As a member of the Berkshire Hathaway insurance group, BHHC has earned an enviable record of success in the insurance industry that is supported by an A++ A.M. Best rating, the highest rating they award insurance carriers. Our corporate size enables our organization to react swiftly and effectively to opportunities in the insurance marketplace. At the same time, our financial strength provides our agents and insureds the security rarely available in a regional specialty carrier.

We value each individual and recognize that attracting and retaining high quality talent is essential to the success of our company. Our structure minimizes bureaucracy and creates an environment that encourages our employees to see the direct effects of their hard work throughout the company. Each division provides hands on training and maintains a small company feel, creating an atmosphere in which 'team players' thrive.

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