The UPIC Investigator is responsible for investigating allegations of fraud, waste, and abuse perpetrated by healthcare providers, facilities, members, and/or groups of low to moderate level complexity as assigned and assists in other cases as requested. This position will proactively identify areas of concern through the use of software, tips, interviews, and other means. The incumbent will develop, complete, and resolve investigations of low to moderate level complexity as assigned and assist as needed on investigations of high levels of complexity. Incumbent will collaborate with internal UPIC department and function as an investigative liaison to facilitate change and process improvement recommendations as a result of deficiencies found during investigations to prevent future occurrences of fraud, waste, or abuse.
Investigation: Determines the most effective and efficient methods of investigation for each case. Gathers and analyzes data from internal and external resources including claims, data, medical records, contracts, and public record information. Collects and preserves detailed evidence in a manner that protects its integrity in the event of prosecution. Participates in team interviews of witnesses, accomplices, and suspects. Thoroughly documents all steps of investigations. Uses professional judgement and discretion in case development and prioritization. Interprets and analyzes complex data.
Project Management: Submits claims for adjustment in accordance with established processes. Uses professional judgement and discretion in case development and prioritization. Works with management and UPIC Senior Investigator to report cases of suspected fraud to required parties in compliance with state and federal law. Testifies and gives depositions on behalf of UPIC in conjunction with conducted investigations as requested. Submits any recommendations for internal process improvement to prevent future fraud, waste, or abuse occurrences. Assists in the suggestion, development, implementation, and testing of new system edits to prevent fraud, waste, and abuse.
Collaboration: Collaborates regularly with the UPIC Investigations Manager and/or Senior Investigator to review case progress and next steps and when special challenges arise. Collaborates with appropriate resources as needed such as Fraud, Waste, and Abuse (FWA) Coding Analyst, other UPIC staff, Medical Management, etc. Collaborates with the investigation team to determine case adjudication, unsubstantiated, education, and follow up, administrative, civil, or criminal prosecution and submit through established processes. Provides and seeks constructive feedback. Cross-trains others and seeks cross-training for self.
Case Review and Analysis: Reviews appropriate reports to determine if any new concerns with case subject are identified. Notifies original Investigator and UPIC Investigations Manager of findings. Uses software and other resources to proactively identify aberrant and/or suspect fraud, waste, or abuse practices. Reviews identified concerns with the UPIC Investigations Manager regularly to determine appropriate next steps. Works to facilitate and/or promote process improvement and system change recommendations. Maintains a log of cases and dates due for follow up.
Education and Development: Maintains excellent working knowledge of CMS regulations, processing guidelines and systems and seeks opportunities to increase knowledge and skills. Maintains and/or develops working knowledge of main UPIC systems to help UPIC staff determine the best tool for each step of an investigation. Is dependable, flexible, and adaptable, supporting decisions made. Promotes professional behavior in work, actions, and attitude. Demonstrates self-initiative and persistence in completing projects. Accepts responsibility for job performance in both quality and quantity.
JOB SPECIFIC COMPETENCIES
Analytical Thinking: Ability to identify, understand and determine the significance of issues, causes, problems and opportunities; ability to implement standard course(s) of action to resolve issues within established timeframes and administrative and technical requirements; use effective approaches for choosing a course of action or developing appropriate solutions and/or reaching conclusions.
Attention to Detail: Demonstrates thoroughness in accomplishing a task through concern for all the areas involved; monitors and checks work or information then plans and organizes time and resources efficiently; validates and ensures that data and use of data in reports remains accurate.
Organization and Task Orientated: Consistently maintains a high level of productivity and has the ability to identify the highest priority assignments in a department where workflow is extremely time-sensitive; manages time effectively so that the right time is allocated to the right activity. Implements changes in operations or procedure that provides process improvement.
Decision Making: Ability to make determinations by following specific guidelines, standard operating procedures, rules, and regulations; ability to consult supervisor as necessary prior to making determinations or conclusions; ability to commit to action and implement decisions within a reasonable time.
Problem Solving/Critical Thinking: Has a structured approach to solving problems, demonstrates planning and analytical skills to deliver on results.
Constant Innovation: Seizes opportunities to advance progressive change.
Service Excellence: Provides value through quality service.
Responsible Stewardship: Manages all resources entrusted to them with efficiency and care.
Effective Collaboration: Works together towards a common purpose.
Integrity: Does the right thing
EDUCATION AND EXPERIENCE REQUIREMENTS
Education Details: Associate's degree in Criminal Justice, Health Information Technology, Information Technology, or related field required. Bachelor's degree preferred.
Experience Details: Minimum 1 year insurance fraud, law enforcement, fraud and abuse auditing preferred.
Equivalent combination of education, experience or training determined to be acceptable by Human Resources may be substituted, unless regulated by contract or program standards
Job Posting Policy 6.05
New employees with Noridian Healthcare Solutions will be eligible to apply for positions within their assigned department after successfully completing a 90-day review. For positions outside your department, you must attain a minimum of six months of service before you can apply.Equal Employment OpportunityEqual Opportunity Employer of Minorities, Females, Protected Veterans and Individual with Disabilities, as well as Sexual Orientation or Gender Identity.For questions, please email [Click Here to Email Your Resumé].
This job posting will be closed 2/03/2017 at 8:00AM CST. No further applications will be considered.