For roles that are 100% remote or hybrid, you must have access to a reliable high-speed internet connection to support daily job responsibilities. A minimum bandwidth of 50 Mbps download and 5 Mbps upload is required. Those fully remote associates residing in states where service is required by contract, law, or regulation will be allowed to submit for reimbursement.

Role Overview:

The Investigator is responsible for conducting comprehensive investigations of reported, alleged or suspected fraud involving the full range of products at the AmeriHealth Caritas Family of Companies (ACFC).

Work Arrangement:

• Remote with limited Geography- Must reside in DC or surrounding areas contractually: Montgomery, Prince George's, MD, or Arlington or Fairfax, Virginia, counties or cities of Alexandria and Falls Church, VA. Site visits required as needed.

Responsibilities:

• Ensures compliance with all requirements related to Special Investigation Units and fraud, waste and abuse investigations.
• Conducts investigations of potential fraud, waste and/or abuse with a focus on thoroughness and attention to detail, quality, timeliness and cost control.
• Conducts comprehensive interviews with providers, members and witnesses to obtain information which would be considered admissible under generally accepted criminal and civil rules of evidence.
• Proactively performs research using the Internet, data analysis tools, etc., to analyze aberrant claims billing and practice patterns.
• Analyzes data as part of the investigative process using available fraud detection software and corporate resources.
• Represents ACFC in conducting settlement negotiations with providers, counsel and/or other associated parties.
• Prepares and submits investigative reports covering all phases of the investigation.
• Interprets and conveys highly technical information to others.
• Establishes and maintains liaison with public officials, law enforcement and others to obtain assistance in conducting investigations.
• Performs necessary functions to support all aspects of SIU investigations and responsibilities to include, but not limited to: Intake; Screening; Reviews; Referrals; Recoveries; and Provider Investigative Site Visits.

Education/ Experience:

• Bachelor's degree with a minimum of two years of experience in the healthcare field working in fraud, waste, and abuse investigations and audits OR
• An associate's degree, with a minimum of four years of experience working in healthcare fraud, waste, and abuse investigations and audits.
• Experience and training/certifications commensurate with position requirements in lieu of formal educational requirements for the SIU Investigator position may be considered.
• Valid driver's license required
• Experience with Data Analytics preferred.
• Ability to work independently with minimal supervision, and manage a high volume of assignments.
• Strong verbal and written communication skills.
• High degree of integrity and confidentiality required handling information that is considered personal and confidential.
• Analytical skills and ability to make deductions; logical and sequential thinker.
• A minimum of 3-5 years experience conducting comprehensive health care fraud investigations; interacting with state, federal and local law enforcement agencies.

Other Skills:

• Health care industry and/or Medicare/Medicaid/Pharmacy/Behavioral Health/Pharmacy Benefit Management knowledge required.
• Clinical Experience preferred
• SIU and/or State Medicaid regulatory compliance work experience preferred.
• Knowledge and proficiency in claims adjudication standards & procedures preferred.
• Solid knowledge of Medicaid, Medicare, and pharmacy benefit laws and requirements; federal, state, civil and criminal statutes.
• Experience with decision support tools used for data analysis.
• Advanced knowledge and experience working on various approaches to fraud, waste and abuse.
• Working knowledge of Microsoft applications, especially Excel required.
• Knowledge of available resources (internal and external) to assist in investigations.

Our Comprehensive Benefits Package

Flexible work solutions including remote options, hybrid work schedules, Competitive pay, Paid time off including holidays and volunteer events, Health insurance coverage for you and your dependents on Day 1, 401(k) Tuition reimbursement and more.

The range displayed in this job posting reflects the minimum and maximum for new hire salaries for the position in the Washington, DC area.
Within the range, individual pay is determined by additional factors, including, without limitation, job-related skills, experience, and relevant education, certifications, or training.
AmeriHealth Caritas associates are eligible to participate in our annual incentive program and will also receive our benefits package, consisting of medical, vision, dental, life insurance, disability insurance, 401(k), paid time off and more.
The targeted hiring range for this role is expected to be between $75,500 and $102,800.