JOB SUMMARY FOR SPECIAL INVESTIGATOR:
- Epitec is seeking a Special Investigator for a full-time contract position with a healthcare company located in Philadelphia, PA.
RESPONSIBILITIES FOR SPECIAL INVESTIGATOR:
- Ensures compliance with all requirements related to Special Investigation Units and fraud, waste and abuse investigations.
- Performance of data-mining activities to identify potential cases for investigation.
- Performing sampling methodologies for medical record requests/reviews (e.g., OIG SVRS tool, Probe or random sampling).
- 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 company 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.
REQUIRED EXPERIENCE FOR SPECIAL INVESTIGATOR:
- A minimum of 3-5 years experience conducting comprehensive health care fraud investigations; interacting with state, federal and local law enforcement agencies.
- Health care industry and/or Medicare/Medicaid/Pharmacy/Behavioral Health/Pharmacy Benefit Management knowledge required.
- 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.
- Associate’s Degree or equivalent work experience.
- Bachelor’s Degree preferred.
SKILLS AND QUALIFICATIONS FOR SPECIAL INVESTIGATOR:
- Valid driver’s license required.
- 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.
Why should you choose Epitec?
We started Epitec with a single focus, “Placing People First.” Knowing every good endeavor begins with listening and understanding, we’ve set about challenging every part of the employment process. Bringing the proper connections together for the perfect fit.
How is Epitec different?
Epitec gets to know our prospective employees, using these insights to locate the perfect placement for you. We are there, every step of the way. Providing a best-in-class compensation package combined with the opportunity to grow financially and personally through your work.
What is the result?
Epitec represents the world’s top companies and works to fill their open jobs with the world’s best talent. That’s led to Epitec servicing an impressive list of Fortune 100 companies. We've also won many awards, including one of Crain’s Detroit Business “Cool Places to Work,” and 101 Best & Brightest – local, national and elite winner. And that’s just the beginning, as we work to innovate the way the world thinks about employment.