Job SummaryBASIC FUNCTION
HCSC is looking for a dynamic individual to join its Internal Investigations team! This position is responsible for managing health care fraud and internal fraud investigations; managing and training investigators and support staff; establishing and maintaining liaison with health care providers and law enforcement; and coordinating anti-fraud activities with other departments at HCSC. This role partners with Compliance, Legal, Audit, Provider Services, Clinical Operations, and external regulatory agencies to detect, investigate, and mitigate fraudulent or abusive activities while ensuring compliance with federal and state healthcare regulations.
NOTE: this role is hybrid/flex and requires in-office visibility three days per week, working from home the other two days; relocation will NOT be provided and sponsorship will NOT be extended either now or in the future.
JOB REQUIREMENTS- Bachelor's Degree.
- 10 years law enforcement/investigation experience or healthcare fraud investigation experience AND 3 years management experience, including supervision of investigators and/or professional certified coders.
- Organizational skills, results oriented with demonstrated leadership skills.
- Experience in the implementation of pre-payment review process.
- Exceptional analytical, problem-solving, and decision-making abilities.
- Strong executive communication and presentation skills.
- PC proficiency to include the MS Office Suite (Word, Excel, PowerPoint, Teams) as well as Workday.
PREFERRED JOB REQUIREMENTS- Certified Professional Coder (CPC) designation.
- Experience with WRIKE (SaaS work management process platform).
KEY FUNCTIONS- Lead the design, implementation, and ongoing optimization of pre-payment review process to identify and prevent fraudulent, wasteful, abusive, or non-compliant claims prior to payment and oversee, monitor and make decisions regarding pre-payment review status of providers.
- Oversee daily volume of claims and monitor program effectiveness through savings, cost avoidance, provider behavior changes, and regulatory compliance metrics.
- Works with internal stakeholders (i.e. claims processing, legal, provider network)
- Utilize claims data analysis, predictive analytics, and fraud detection tools to identify suspicious patterns and activities.
- Manage and develop a team of professional certified coders and investigative analysts.
NOTE: this role is hybrid/flex and requires in-office visibility three days per week, working from home the other two days; relocation will NOT be provided and sponsorship will NOT be extended either now or in the future.
Are you being referred to one of our roles? If so, ask your connection at HCSC about our Employee Referral process!Pay Transparency Statement:At Health Care Service Corporation, you will be part of an organization committed to offering meaningful benefits to our employees to support their life outside of work. From health and wellness benefits, 401(k) savings plan, pension plan, paid time off, paid parental leave, disability insurance, supplemental life insurance, employee assistance program, paid holidays, tuition reimbursement, plus other incentives, we offer a robust total rewards package for employees. Learn more about our benefit offerings by visiting https://careers.hcsc.com/totalrewards.
The compensation offered will vary depending on your job-related skills, education, knowledge, and experience. This role aligns with an annual incentive bonus plan subject to the terms and the conditions of the plan.
Base Pay Range$92,700.00 - $167,500.00
Exact compensation may vary based on skills, experience, and location.
