Owings Mills, MD
Industry: Accounting, Finance & Insurance•
8 - 10 years
Posted 88 days ago
PRINCIPAL ACCOUNTABILITIES: Under the direction of the SI Manager, functions include but are not limited to:
Supporting management and providing input into the coordination, planning, organizing and direction of the case workload, and supervising, training, and developing less experience staff. This include day-to-day supervision, approval of investigative plans, and performance management responsibilities. Assists manager with the development of departmental goals, policies, and objectives and activities of the Department to identify, investigate, resolve and prevent fraud, waste, and abuse. Conduct quality reviews on departmental work and make recommendations for improvement. Conduct training seminars for associates to increase awareness of possible fraudulent activities in order to prevent corporate losses.
Develops and conducts complex investigations. Performs audits of financial business records, provider and subscriber medical data, claims, systems’ reports, and medical records. Analyzes contract documents, provider/subscriber claims history, benefits, external data banks and other documents to determine the possible existence of fraud and/or abuse. Conducts detailed offsite audits/investigations with interviews when appropriate. Researches provider/subscriber claims activity, operations manuals, data systems, medical policies, job duties and group benefit contracts to identify control deficiencies and non-compliance. Develops documentation to substantiate findings including formal reports, spreadsheets, graphs, audit logs, anti-fraud software and appropriately sourced reference materials. Ensures audits and investigations are timely, effective and result in an overall achievement of unit goals.
Ensures timely maintenance of case file, case management system and case updates and preserves as potentially discoverable material. Compose and approve formal correspondence and detailed technical writing of reports and synopses. Utilizes approved case tracking system and the FEP SIU Tracking System (FSTS). Provides litigation support for civil/criminal court proceedings by collaborating with internal departments/external agencies. Establishes and maintains liaisons with the OPM-OIG, Insurance Administration Fraud division, Federal Bureau of Investigation, Postal Inspector, Office of the Inspector General for all Federal Agencies, Department of Justice, Department of Defense, Drug Enforcement Administration, Internal Revenue Service, Secret Service, state licensing boards, state/local law enforcement, etc. to maintain lines of cooperation/communication with external agencies that pursue prosecution of fraud and/or abuse cases. Conduct onsite audits and field interviews when needed.
In conjunction with team perform root cause analysis on cases worked by the department to identify problems and provide recommendations to management and the payment integrity workgroup, as they relate to risk mitigation and effective external/internal controls for CareFirst Business Operations.
Assist in the initiation claim adjustments, court ordered restitution, settlement agreements, promissory notes, voucher deducts and voluntary refunds in order to recover funds. Interprets State/Federal criminal statutes and criminal and civil law impacting insurance fraud/abuse investigations to preserve the integrity of the investigation and to determine its effect on corporate risk issues, policies and procedures. Apprises management and General Counsel of the same. Testifies as a qualified expert witness on case findings in the grand jury, court trials, and hearings to conclude fraud/abuse cases to recover corporate funds.
Perform special projects to meet the needs of the Special Investigations Unit.
SUPERVISORY RESPONSIBILITY: The candidate will be required to perform in the role of Supervisor. This will entail the incumbent to direct the work of their direct report investigators. .
Required: A 4-year college degree and 7 or more years of work experience in insurance, investigative, health care, nursing or law enforcement, or total work experience equivalent, at least 3 of which must be health care specific, and includes experience independently leading all levels of fraud, waste and abuse investigations. At least one additional credential in a health care or investigations related area such as Certified Fraud Examiner (CFE), Accredited Health Fraud Investigator (AHFI), RN/LPN, or Certified Professional Coder (CPC).