Special Investigator

Responsible for conducting and leading internal and external investigations for designated lines of business (Commercial, OGB, FEP, ITS, Medicare Advantage, Vantage, etc.), to ensure payment integrity within the respective programs. Provides management with insights and recommendations to, deter, detect, prevent and recover losses due to fraud, waste, and abuse. Accountable for complying with all laws and regulations that are associated with duties and responsibilities.

• This role does not manage people
• This role reports to this job: Manager, Special Investigations
• Necessary Contacts: In order to effectively fulfill this position, the incumbent must be in contact with:
  
  Employees at all levels. Providers, subscribers, group leaders, external consultants, attorneys, external auditors, governmental agencies, all levels of prosecutorial agencies, other Blue Plans, and agencies/businesses as needed.

• Bachelor's in Audit, Accounting, Criminal Justice, Nursing or another related field as deemed necessary by department management is required.
• Four years of related experience can be used in lieu of a Bachelor’s degree.

• 3 years experience in a predominantly analytical position related to fraud investigations, audits, medical procedures or coding. required

• Excellent communication, negotiation, and interrogation skills. Must be capable of taking the lead in interviews with witnesses, suspects, and/or their attorneys.
• Ability to manage time, cases, and partner with assigned analyst(s) to determine plan of action and assign specific tasks to be completed in relation to the case on a daily basis.
• Ability to travel 20% to 40% of time in order to conduct Provider/Subscriber on-site reviews and face-to-face meetings for assigned cases. Travel is largely in state; however, national travel, as well as some overnight travel, is also required.
• Ability to conduct interviews in which 70% of interviews are face-to-face in order to assess body language of interviewees.
• Must have proficient computer skills, including knowledge of Microsoft programs.

• Requires an approved certification or medical license such as CIA, CPA, CFE, CISA, POST, RN, LPN or other business or clinical licensures as approved by department management.
• Non Clinical\AZDL - Driver Licence - Valid And In State Good driving record as well as use of an automobile that is properly licensed and insured pursuant to all legal requirements.

• Deter, detect, and investigate fraudulent and abusive activity and independently decide the most effective and efficient method of investigation for each individual case.
• Manage a full caseload – perform multiple high-quality investigations concurrently by prioritizing work and delegating activities to Analysts and other team members if necessary.
• Gather and analyze data and information from internal and external sources – including claims history databases, public record information systems, other insurance carriers, and law enforcement officers.
• Collect and preserve detailed evidence.
• Prepare cases for referral to law enforcement and regulatory agencies.
• Testify and give depositions on behalf of Company as a witness in legal proceedings with appropriate oversight.
• Document all stages of each investigation using Company and department procedures, templates, and forms.
• Prepare post-investigative reports directed towards the prevention of fraud through the identification of root-cause problems and issues in the Company’s claims payment systems, contracts, policies and procedures.
• Handle highly confidential and sensitive information while ensuring compliance with the Company’s privacy policies.
• Participate on special projects, committees, and task forces as requested by management.
• Reduce or eliminate Medicare Part C and D benefit costs due to fraud, waste, and abuse.
• Reduce or eliminate fraudulent and abusive claims paid for with federal dollars.
• Refer suspected, detected, or reported cases of illegal drug activity, including drug diversion, to Centers for Medicare & Medicaid Services’ National Benefit Integrity Medicare Drug Integrity Contractors (NBI MEDIC) and/or law enforcement and conduct case development and support activities for the NBI MEDIC and law enforcement.
• Assist law enforcement by providing information necessary for legal action as requested by management.

• Perform other job-related duties as assigned, within your scope of responsibilities.
• Job duties are performed in a normal and clean office environment with normal noise levels.
• Work is predominately done while standing or sitting.
• The ability to comprehend, document, calculate, visualize, and analyze are required.