Investigator I, II-Louisiana Remote (PS36318)

Description SHIFT: Day JobSCHEDULE: Full-timeInvestigator I, IIThis position must sit in Louisiana but will be a remote position. This position can be filled at either the level I, or level II. Investigator I Responsible for investigating assigned cases, collecting, researching and analyzing claim data in order to detect fraudulent, abusive or wasteful activities/practices. Primary duties may include, but are not limited to:

Using appropriate system tools and databases for analysis of data and review of professional and facility claims to detect fraudulent, abusive or wasteful healthcare insurance payments to providers and subscribers.

Preparation of statistical/financial analyses and reports to document findings and maintain up-to-date electronic case files for management review.

Preparation of final case reports and notification of findings letters to providers.

Receive offers of settlement for review and discussion with management.

Communication skills, both oral and written required for contact with all customers, internal and external, regarding findings.

Investigator II Responsible for the identification, investigation and development of cases against perpetrators of healthcare fraud in order to recover corporate and client funds paid on fraudulent claims. Primary duties may include, but are not limited to:

Claim reviews for appropriate coding, data mining, entity review, law enforcement referral, and use of proprietary data and claim systems for review of facility, professional and pharmacy claims.

Responsible for identifying and developing enterprise-wide specific healthcare investigations that may impact more than one company health plan, line of business and/or state.

Must be able to effectively establish rapport and on-going working relationship with law enforcement.

May interface internally with Senior level management and legal department throughout investigative process.

May assist in training of internal and external entities.

Assists in the development of policy and/or procedures to prevent loss of company assets.

Health insurance, law enforcement experience preferred.

Qualifications Investigator I

Requires BA/BS, 2+ years related experience preferably in healthcare insurance departments such as Grievance and Appeals, Contracting or Claim Operations, law enforcement; or any combination of education and experience, which would provide an equivalent background

Healthcare Investigations experience is an asset

Proficient in Microsoft Office

Must reside in Louisiana

Investigator II

Requires BA/BS degree, 3+ years related experience; or any combination of education and experience, which would provide an equivalent background.

Fraud certification from CFE, AHFI, AAPC or coding certificates preferred.

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

Healthcare Investigations experience is an asset

Proficient in Microsoft Office

Must reside in Louisiana

AnEqualOpportunityEmployer/Disability/VeteranREQNUMBER: PS36318