This position is responsible for conducting objective, thorough, and timely investigations into allegations of healthcare fraud, waste or abuse (FWA). These investigations will require effective interaction with SCAN Departments that are responsible for member, provider, case management and compliance.
ESSENTIAL JOB RESULTS:
Investigate and analyze FWA referrals from various sources including, but not limited to member complaints, hot line calls, and referrals from other SCAN departments.
Support investigations through research, using SCAN data sources of claims, encounters, pharmacy, case management records and interviews of related parties.
Build case evidence to clearly support a conclusion of substantiated or unsubstantiated FWA that will be presented to management for approval.
Document the investigation in a clear and concise manner within the Special Investigations Case Management tools and systems.
Assist in the development of trends based on internal and external data that may highlight potential behaviors.
Prepare statistical and financial analysis to document findings where appropriate.
Create detailed case summaries for presentation to regulators, management and other parties.
Develop recommendations for corrective actions to management.
Perform all investigative activities within the established regulatory (CMS, etc.) requirements for FWA.
Research and respond to inquires from the National Healthcare Anti-Fraud Association, regulators, enforcement agents, etc.
Maintain strong working relationships with all SCAN departments to facilitate organizational communication and enhance our fraud prevention processes.
Maintains professional and technical knowledge through education and building relationships with industry and regulatory experts.
Bachelor's Degree, or equivalent experience.
3 years fraud investigations experience with exposure to medical and pharmacy claim processing, government programs (Medicare, Medicaid, etc.).
Working knowledge of medical terminology, health plan operations and fraud, waste and abuse issues/schemes/prevention techniques.
Strong system skills including the ability to design and create moderate to complex queries of health care data.
Excellent computing skills with knowledge or Word, Excel, PowerPoint, Access and specialized audit software.
Strong analytical and investigative skills to be able to self-direct the proper and most efficient path to reaching a conclusion.
Ability to travel to SCAN offices and business partners as needed to perform audits.
Excellent written and verbal communication skills used for interviewing and corresponding with claimants, attorneys, doctors, law enforcement, etc.
A high degree of integrity and confidentiality is required for handling information that is considered personal and confidential.
Preferred experience with healthcare fraud detection and prevention software packages.
CONDITIONS OF WORK:
Office Hours: Monday-Friday, 8am to 5pm. Extended work hours, as needed.
Position will operate out of our Long Beach Headquarters.
Since we started in 1977, our mission has been the same: Keeping seniors healthy and independent. As one of the largest not-for-profit...