Fraud Examiner

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Job Summary

This position is responsible for identifying, developing, and managing complex, high-impact healthcare fraud investigations resulting in criminal and/or civil prosecution; and may be responsible for establishing and maintaining close liaison, as indicated in Plan design, with internal department personnel, and government officials including law enforcement to further SID investigations and referrals for prosecution of healthcare investigations.

Responsibilities

• Identify, develop, and manage complex, high impact health care fraud investigations. These investigations can involve multiple customers and/or states and are likely to result in criminal or civil prosecution.
• Utilize available sophisticated investigative techniques including interviewing providers, subscribers, pharmacists, lawyers. Some interviews may be confrontational necessitating enhanced interviewing skills.
• Prepare timely, well written and detailed investigative reports which support recommended actions to include referral to law enforcement.
• Coordinate efforts of the department with local, state, and federal investigators and prosecutors. Coordinate and lead task force cases which involve participation of internal departments, external law enforcement and other insurance plans. May regularly contact these officials to maintain liaison and receive/provide updates concerning ongoing and anticipated investigative efforts.
• Act as team leader on specific projects and complex investigations, lead and coordinate work of other investigators to ensure thorough and complete investigation, including oversight of evidence handling and report writing to ensure proper documentation of investigation activities.
• Work closely with internal HCSC departments, e.g., Legal, Marketing, HCM, SSD, Network Administration and Human Resources, to enhance effectiveness of SID investigations and operations. Coordinate with these and other HCSC departments, as necessary, to advance ongoing anti-fraud program and contribute toward protecting assets of the corporation.
• Manage sensitive investigations, including those involving HCSC employees, when requested. Such investigations may include urgent matters to be handled on behalf of the Security and Compliance Departments.
• Develop sources of information, internal/external, to assist in identification of health care fraud, e.g., working collaboratively with SID’s Intelligence Unit to develop new, or further existing, investigations.
• Ensure evidence, including documents, is properly collected, and maintained in a manner to ensure integrity in court proceedings.
• Support criminal and civil court actions by providing assistance in pretrial preparation as requested and through deposition or court testimony as required. Act in an undercover capacity consistent with SID Undercover Policy to advance cases through proactive investigative activities.
• May participate in or lead presentations regarding SID’s mission, methods, and requests for assistance in combating Health Care Fraud. These presentations may be made available, as indicated in Plan design, to employees and external audiences (providers, billers/coders, members, Law Enforcement). May actively solicit opportunities to provide such presentations and provide this service in coordination with other concerned departments as indicated in Plan design.
• Organize evidence obtained in investigations for presentation to the Assistant U.S. Attorney, State’s Attorney, State Attorney General, Federal Bureau of Investigation, Investigations Medicare Drug Integrity Contractor, Local Law Enforcement including the Medicaid Fraud Control Units, State Offices of Inspector General, State Licensing Agencies, HCSC internal departments, and external Attorneys.
• Conduct investigative work so that SID is following and in compliance with state and federal regulations that govern reporting and investigative work within the MAPD, PDP, Medicaid, and Dual Eligible Programs.
• Communicate and interact effectively and professionally with co-workers, management, customers, etc.
• Comply with HIPAA, Diversity Principles, Corporate Integrity, Compliance Program policies and other applicable corporate and departmental policies.
• Maintain complete confidentiality of company business.
• Maintain communication with management regarding development within areas of assigned responsibilities and perform special projects as required or requested.

JOB REQUIREMENTS:

• Bachelor’s Degree
• 7 years law enforcement experience (local, state, or federal) or 7 years fraud investigative experience.
• Experience directing complex fraud investigations which result in criminal or civil prosecutions.
• Experience planning and conducting interviews which develop significant information in furtherance of complex fraud, waste, and abuse investigations.
• Familiarity with state and federal laws applicable to health care fraud.
• Ability to develop effective liaison relations which facilitate case identification, investigation, and prosecution.
• Ability to independently prepare reports of interview and other documentation accurately reflecting investigative activity and results.
• Clear and concise verbal and written communication skills.
• Self-motivated, results oriented with demonstrated leadership skills.

PREFERRED REQUIREMENTS:

• Accredited Health Care Fraud Investigator
• Certified Professional Coder
• Certified Fraud Examiner

** We encourage people of all backgrounds and experiences to apply. Even if you don’t think you are a perfect fit, apply anyway – you might have qualifications we haven’t even thought of yet.

**Please note that this position is based at the Richardson HQ where you work 3 days in the office and 2 days from home.

*CA

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HCSC Employment Statement:

HCSC is committed to diversity in the workplace and to providing equal opportunity and affirmative action to employees and applicants. We are an Equal Opportunity Employment / Affirmative Action employer dedicated to workforce diversity and a drug-free and smoke-free workplace. Drug screening and background investigation are required, as allowed by law. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status.