Senior Investigator, Special Investigations

Job Description

A bit about this role: 

The Senior Investigator, Special Investigations will play a crucial role in investigating allegations of healthcare fraud, waste, and abuse. This position is responsible for planning, organizing, and executing complex and specialized investigations or audits aimed at preventing, detecting and responding to potential fraudulent activities to protect our members and the Medicare Fund.

Your Responsibilities and Impact will include:

• Perform data mining and analysis to detect aberrancies and outliers in claims, medical records, enrollment records, or other relevant healthcare transactions; independently researches FWA issues and effectively employs investigative resources/techniques.

• Handle complex investigations that require advanced investigative knowledge/skills.

• Acts as subject matter expert for SIU Investigator(s), providing specialized knowledge and guidance.

• Mentor and assist with training SIU staff and internal business partners. Assist in the development and presentation of FWA training.

• Assist in development of policies and procedures related to fraud, waste, and abuse detection and investigation. Support the development and execution of the annual SIU risk assessment and work plan.

• Conduct provider education in response to investigations and audits. 

• Refer issues to the appropriate parties (e.g., regulators, law enforcement); ensuring comprehensive summary and detailed reports on investigative findings for referral to federal and state agencies are in compliance with regulatory requirements.

• Responsible for creating and presenting FWA reports to Senior leaders, including summarizing identified trends and patterns indicative of potential FWA with recommendations for prospective and retrospective detection, investigation, recovery and avoidance programs.

• Serve as the primary point of contact for corporate and field inquiries regarding fraud, waste, and abuse. Collaborate with relevant stakeholders to facilitate the recovery of funds and/or any other internal actions deemed necessary and appropriate in the resolution of detected FWA (e.g., contract termination, education).

• Collaborate with and provide regular updates on current FWA schemes,  progress of investigations and coordinate with internal stakeholders on recommendations, actions, and resolutions (e.g., FWA Monthly Workgroup, Market/Network, Credentialing Committee, FWA Subcommittee).

• Arrange, conduct, and participate in meetings with providers, business partners, and representatives from regulatory agencies and law enforcement regarding ongoing investigations. Participate in OIG Healthcare Fraud Workgroups.

• Lead investigations into Agent Broker allegations of fraudulent behavior. 

Required skills and experience:

• Bachelor’s Degree in Business, Criminal Justice, Healthcare, or a related field, or equivalent experience.

• A minimum of 3 years of experience in health insurance fraud investigation

• Experience in Medicare and/or Medicaid programs, specifically with medical claim billing, reimbursement, audit, or provider contracting.  

• Demonstrated Experience with conducting internal employee investigations and investigations involving contracted sales agents and agencies. 

• Experience with data analysis techniques and AI concepts for business processes.

Desired skills and experience:

• Strong analytical skills with the ability to interpret complex data sets.

• Excellent written and verbal communication skills for report writing and stakeholder engagement.

• Detail-oriented with a strong commitment to integrity and compliance.

• Ability to work independently and collaboratively in a fast-paced environment.

• Strong organizational skills and the ability to manage multiple investigations simultaneously.

Licenses/Certifications:

• Certified Fraud Examiner (CFE) and/or Certified Professional Coder (CPC) certification is preferred.

#LI-Remote
#LI-DS1

Salary range: $75,000 - $110,000 / year

The pay range listed for this position is the range the organization reasonably and in good faith expects to pay for this position at the time of the posting. Once the interview process begins, your talent partner will provide additional information on the compensation for the role, along with additional information on our total rewards package. The actual base salary offered will depend on a variety of factors, including the qualifications of the individual applicant for the position, years of relevant experience, specific and unique skills, level of education attained, certifications or other professional licenses held, and the location in which the applicant lives and/or from which they will be performing the job.

Our Total Rewards package includes:

• Employer sponsored health, dental and vision plan with low or no premium

• Generous paid time off

• $100 monthly mobile or internet stipend

• Stock options for all employees

• Bonus eligibility for all roles excluding Director and above; Commission eligibility for Sales roles

• Parental leave program

• 401K program

• And more....

*Our total rewards package is for full time employees only. Intern and Contract positions are not eligible.

Healthcare equality is at the center of Devoted’s mission to treat our members like family.  We are committed to a diverse and vibrant workforce. 

At Devoted Health, we’re on a mission to dramatically improve the health and well-being of older Americans by caring for every person like family. That’s why we’re gathering smart, diverse, and big-hearted people to create a new kind of all-in-one healthcare company — one that combines compassion, health insurance, clinical care, service, and technology - to deliver a complete and integrated healthcare solution that delivers high quality care that everyone would want for someone they love. Founded in 2017, we've grown fast and now serve members across the United States.  And we've just started. So join us on this mission!

Devoted is an equal opportunity employer. We are committed to a safe and supportive work environment in which all employees have the opportunity to participate and contribute to the success of the business. We value diversity and collaboration. Individuals are respected for their skills, experience, and unique perspectives. This commitment is embodied in Devoted’s Code of Conduct, our company values and the way we do business.

As an Equal Opportunity Employer, the Company does not discriminate on the basis of race, color, religion, sex, pregnancy status, marital status, national origin, disability, age, sexual orientation, veteran status, genetic information, gender identity, gender expression, or any other factor prohibited by law. Our management team is dedicated to this policy with respect to recruitment, hiring, placement, promotion, transfer, training, compensation, benefits, employee activities and general treatment during employment.