Easter Seals Jobs

Investigator Lead

Location: This position will work a hybrid model (remote and office). Ideal candidates will live within 50 miles of one of our PulsePoint locations.

The Investigator Lead is responsible for providing leadership and guidance to the Special Investigations Unit team in investigating, collecting, researching and analyzing billing data in order to detect fraudulent, abusive or wasteful activities/practices. Provides comprehensive sound judgment in the application of various investigative methodologies to team members and is able to effectively evaluate and recommend focused investigative activities involving market trends indicating Fraud, Waste and Abuse within the healthcare industry.

How you will make an impact:

• Assisting the team manager with the administration and operational activities occurring within the Special Investigations Unit; coordinating and conducting case reviews for quality assurance, investigative sufficiency, and case data management; and direction of day-to-day operations as assigned by management.

• Through use of appropriate system tools, provides training for and conducts analysis of data to detect fraudulent, abusive or wasteful payments to providers and subscribers.

• Prepares statistical/financial analyses and reports to document findings and maintains up-to-date case files for management review.

• Prepares final report and notification of findings letter suitable for distribution to providers and legal counsel.

• Creates and presents settlement offers for provider issues for review and approval by management and/or legal.

• Communicates orally and in writing with all customers, internal and external, regarding findings.

• Assists management and provides recommendation in support of the development of policy and/or procedures to prevent loss of company assets.

• Prepares and delivers training to internal and external entities.

• Develops and maintains a high degree of rapport and cooperation with the Federal, State and local law enforcement and regulatory agencies which can assist in investigative efforts.

• Represents the Company in court proceedings regarding research findings.

• Provides guidance to investigators and other SIU staff in the development of criminal and recovery cases.

• Leads SIU projects or initiatives.  

Minimum Requirements:

• Requires a BA/BS and minimum of 8 years related experience in healthcare insurance and healthcare insurance investigation; or any combination of education and experience, which would provide an equivalent background.

Preferred Skills, Capabilities and Experiences:

• Professional certification of CFE, AHFI, CPC, Paralegal, RN, JD or other job related designation preferred.

• Knowledge of Plan policies and procedures in all facets of benefit programs management with heavy emphasis in negotiation preferred.