Investigator Fraud Job Description Sample
Welfare Fraud Investigator
DEPARTMENT OF PUBLIC SOCIAL SERVICES
Applications will be accepted starting Monday, June 8, 2015 a.m., PST until the needs of the service are met and is subject to closure without prior notice.
TYPE OF RECRUITMENT:
Departmental Promotional Opportunity
Restricted to current permanent employees of the Department of Public Social Services who have successfully completed their initial probationary period with Los Angeles County.
APPLICANTS MUST MEET THE SELECTION REQUIREMENTS AT THE TIME OF FILING
Current employees in the unclassified service who meet the following criteria also qualify to participate in this exam:
Unclassified employees who have attained permanent County status on a classified position by successful completion of the initial probationary period, with no break in service since leaving the classified service OR full-time employees in the unclassified service with at least six months of full-time experience in the unclassified service by the last day of filing.
No withhold will be accepted for this examination.
VERIFICATION OF EXPERIENCE:
No out-of-class experience or Verification of Experience Letter (VOEL) will be accepted.
Investigates allegations of welfare fraud.
Positions allocable to this class report to a Supervising Welfare Fraud Investigator and are responsible for conducting intensive investigations surrounding allegations of welfare fraud, including collecting and evaluating evidence, determining violations of welfare laws and regulations, preparing requests for criminal complaints, and assisting in the prosecution of cases. Incumbents must exercise a good working knowledge of techniques, laws, and regulations pertaining to investigations of welfare fraud.
Essential Job Functions
Analyzes and evaluates information and/or allegations of welfare fraud.
Develops and implements an appropriate investigation plan based on information received.
Discusses allegations of suspected welfare fraud with eligibility and social work staff to explain findings and to identify facts.
Interviews employers, neighbors, and other possible witnesses, and conducts surveillance and makes use of related community resources to obtain information concerning employment, living arrangements, and other matters concerning suspected welfare fraud.
Testifies in court as the investigating officer to provide testimony in welfare fraud cases.
Makes unscheduled home visits to determine if current living arrangements violate welfare regulations.
Makes referrals of suspected child abuse and/or neglect or elder abuse to the appropriate agency.
Interviews suspects to obtain information regarding allegations.
Prepares and serves search warrants on businesses or institutions to secure evidence to support allegations of welfare fraud.
Reviews computation of fraudulent overpayments for accuracy and correct application of regulations; conducts interviews with suspects to discuss and arrange for restitution of fraudulent overpayments.
Arrests and books welfare fraud suspects who surrender at the Criminal Courts Building.
Analyzes investigative findings to determine whether evidence warrants referral to the District Attorney's Office for consideration for filling a criminal complaint; prepares written investigative summaries and assists attorneys assigned to cases in criminal prosecutions; testifies in court as to conduct of investigation and/or methods of evidence collection.
One year of experience in the County of Los Angeles' class of Welfare Fraud Investigator Trainee.
A valid California Class C Driver License or the ability to utilize an alternative method of transportation when needed to carry out job-related essential functions.
Physical Class II - Light. Involves light physical effort which may include occasional light lifting to a 10-pound limit, and some bending, stooping, or squatting. Considerable walking may be involved.
SPECIAL REQUIREMENT INFORMATION:
As a condition of employment as a Welfare Fraud Investigator: All persons appointed on or after January 1, 2001, are required by law (AB 2059) to attend and successfully complete a Specialized Investigator Basic Course (SIBC) approved by POST (Peace Officer Standards and Training Commission) within one year of appointment.
This is a very physically demanding and academically intensive 16-week police academy course. During the SIBC, individuals must demonstrate proficiency in law enforcement related academics and the use of firearms. Welfare Fraud Investigators who do not complete the SIBC will be restored to their previously held permanent position or nearest equivalent position.
Candidates must meet qualifications for designation as a Peace Officer set forth in the California Government Code. All candidates considered for appointment will undergo a background check to ensure that they are POST-eligible under the five criteria listed below:
At least 18 years of age
No felony convictions
Of good moral character
Citizen of the United States or a permanent resident alien who is eligible for and has applied for citizenship, except as provided in Section 2267 of the Vehicle Code.
High school graduation-OR-pass the General Education Development Test indicating high school graduation level-OR-pass the California High School Proficiency Examination-OR- have attained a two-year or four-year degree from an accredited college or university.
To qualify, applicants must have current status as a Welfare Fraud Investigator Trainee as evidenced by holding such a payroll title in the service of the County of Los Angeles for the required period of time.
Please note that all information included in the application materials is subject to VERIFICATION at any point during the examination and hiring process, including after an appointment has been made.
FALSIFICATION of any information may result in DISQUALIFICATION.
Utilizing VERBIAGE from Class Specification and Minimum Requirements serving as your description of duties WILL NOT be sufficient to meet the requirements. Doing so may result in an INCOMPLETE APPLICATION and you may be DISQUALIFIED.
This examination will consist of two (2) parts:
Part 1: An evaluation of experience based on application information weighted 50%. Candidates must achieve a passing score of 70% of higher to advance to the Appraisal of Promotability.
Part 2: An Appraisal of Promotability weighted 50%. This part of the exam will evaluate the following dimensions:
Knowledge and Skills
Analytical & Decision-Making Abilities
Applicants must meet the Selection Requirements and achieve a passing score of 70% or higher on each weighted part of the examination in order to be placed on the Eligible Register.
The names of candidates receiving a passing grade in the examination will be placed on the eligible register in order of their score group for a period of twelve months following the date of promulgation. No person may compete in this exam more than once in a twelve (12) month period.
FINGERPRINTING AND SECURITY CLEARANCE:
Before a final appointment is made to this position, candidates are subject to security clearance which includes fingerprinting. Any candidate with a conviction record incompatible with the essential duties of this position may be withheld from appointment.
Any false statement or omission of material fact may cause forfeiture of employment rights. Information presented on employment applications, resumes, and during the examination process is subject to verification. Disqualifying factors may include but are not limited to the following:
Certain job-related misdemeanor convictions
Certain serious traffic convictions or traffic violations (e.g., three or more moving violations within the past two (2) years, failure to appear, at-fault accidents, and driving under the influence)
Illegal use of certain controlled substances
The resulting eligible register for this examination will be used to fill vacancies in the Department of Public Social Services offices located throughout Los Angeles County.
APPLICATION AND FILING INFORMATION:
Applications must be filed online only. We must receive your application by 5:00 p.m., PST, on the last day of filing.
Applications submitted by U.S. mail, fax, or in person will not be accepted. Apply online by clicking on the "Apply" tab for this posting. You can also track the status of your application using the website https://www.governmentjobs.com/careers/lacounty.
Applicants must submit all documents to be considered (diplomas, official transcripts, certificates, etc.) during application submission. All documents must be clear and legible. Although resumes can be uploaded as attachments to the application, resumes cannot be accepted in lieu of completing the online application.
Documents not submitted with the application may be emailed to ExamsUnit@dpss.lacounty.gov, but must be received within fifteen (15) calendar days of filing.
All emails must clearly identify the applicant's name and the subject line must include the exam name Welfare Fraud Investigator and exam number 49152P.
Acceptance of your application depends on whether you clearly show that you meet the Selection Requirements. Fill out the online application completely and correctly in order to receive full credit for any related education, training, and job experience.
For each job held, give the name and address of your employer, your job title, beginning and ending dates, description of work performed and salary earned. Utilizing verbiage from the Class Specification and Selection Requirements will not be sufficient to demonstrate that you meet the requirements. Doing so may result in an Incomplete Application and disqualification.
All information supplied is subject to verification. APPLICATIONS MAY BE REJECTED AT ANY STAGE OF THE SELECTION PROCESS. Falsification of any information may result in disqualification or rescission of appointment. WE MAY CLOSE THIS EXAMINATION WITHOUT PRIOR NOTICE.
PLEASE REVIEW YOUR APPLICATION CAREFULLY AND COMPLETELY PRIOR TO CLICKING THE "SUBMIT" BUTTON
SOCIAL SECURITY NUMBER:
Please include your Social Security Number for record control purposes.
Federal law requires that all employed persons have a Social Security Number.
COMPUTER AND INTERNET ACCESS AT PUBLIC LIBRARIES:
For candidates who may not have regular access to a computer or the internet, applications can be completed on computers at public libraries throughout Los Angeles County.
NO SHARING OF USER ID AND PASSWORD:
All Applicants must file their application online using their own user ID and password. Using a family member or friend's user ID and password may erase a candidate's original application record and is subject to disqualification for this examination.
Questions regarding this posting may be emailed, with exam name Welfare Fraud Investigator and exam number 49152P in the subject line, to ExamsUnit@dpss.lacounty.gov.
Americans with Disabilities Act (ADA) Coordinator Phone: (213) 639-5902 or send requests to: firstname.lastname@example.org
Teletype Phone: (800) 897-0077
California Relay Services Phone: (800) 735-2922
Department Contact Name: Jenny Zeng or Veronik Geragoosian
Department Contact Phone: (213) 639-5556 or (213)639-5546
Department Contact Email: ExamsUnit@dpss.lacounty.gov
Fraud Investigator II
An ongoing evaluation and auditing process is critical to the successful compliance program. The Office of the Inspector General indicates the necessity of thorough monitoring and the implementation of reporting the findings.
The reports of these monitoring should include identified areas of suspected non-compliance, risk assessment and include corrective action. The Fraud Audit Department is responsible for the company's audit functions for determining financial payment accuracy of medical claims as well as system set-up for contract, capitation and fee for service configuration and pre-payment software edits.
The investigator will be in a position of trust, a role that requires integrity, confidentiality, intensity and the utmost commitment in ensuring customer satisfaction through timeliness in meeting or exceeding customer and internal standards.
- Perform in depth analysis and investigation of potential fraudulent healthcare claims and prepare supporting documentation for further actions.• Utilize data analysis techniques to determine inconsistencies and create leads for auditing purposes.• Timely and professional documentation of all actions.• Perform investigative practices (conduct interviews, compile documentation and evidence, maintain extensive notes, negotiate and settle cases, arbitration/litigation testimony).• Audit cases holistically and see them through to conclusion.• Work in conjunction with various law enforcement agencies and regulatory bodies.• Follow all laws, rules and regulations when auditing case files.• Perform research and draw conclusions• Interpret laws and regulations as they pertain to each case file.• Education of providers, facilities, law enforcement and other groups related to each case.• Accurate, professional and thoroughly organized case files.• Formatting overpayments based off of review results and proceeding with direct collection from the provider.• Reporting
ATTRIBUTES / QUALIFICATIONSTo perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions. • Excellent written and verbal communication and interpersonal skills.• Ability to exercise independent judgment.• Ability to work independently and as a member of a team.• Able to multi-task and prioritize work.• Ability to "think outside the box" and use information from a variety of sources to make evidence based business decisions guided by policies, procedures and business plans.
CORE REQUIREMENTS• Abides by and demonstrates the company Mission – Vision – Values through both behavior and job performance on a day-to-day basis.• Convey a strong professional image, exhibit interest and positive attitude toward all assigned work.• Adheres to and participates in Company's mandatory HIPAA privacy program / practices and Business Ethics and Compliance programs / practices.• Reviews and adheres to all company policies, procedures, and the Employee Handbook.
PHYSICAL REQUIREMENTS• Must be able to remain in a stationary position 90% of the time.• Occasionally move about the office to access file cabinets, office machinery, etc.• Constantly operates a computer and other office productivity machinery (i.e., a calculator, copy machine, and computer printer). • Frequently communicates via phone and email. Must be able to exchange accurate information in these situations. • Occasionally lift items weighing up to 10 pounds.
Bachelor's Degree in Criminal Justice or related field/or 5 years of insurance claims investigation experience. Knowledge of medical coding, ICD10, HCPCS, HIPAA, etc. a plus.
Experience and Ability to present issues of concern, citing regulatory violations, alleging schemes or scams to defraud. Proficiency in Microsoft Word, Excel and Access. Strong analytical and technical skills. Must have the ability to handle sensitive and confidential materials.
CareCentrix maintains a drug-free workplace in accordance with Florida's Drug Free Workplace Law.
Sr. Fraud Detection Investigator
Responsible for the research, analysis, investigation and resolution of fraudulent activities and any resulting Suspicious Activity Worksheets (SARW) and filing of SARs. Review account records and/or transactions involving potential fraudulent activity submitted to Corporate Security in accordance with the Bank Secrecy Act. May oversee and provide guidance to other Corporate Security colleagues in the preparation of Suspicious Activity Reports (SAR) and submitting data to FinCEN. Conduct internal and workplace violence investigations as needed. Represent Corporate Security in computer-related investigations.
*High school diploma required.
*Minimum of 7 years of experience working at a financial institution required.
*Minimum of 5 years of Fraud investigation experience required.
Bachelor's degree preferred.
Must have excellent knowledge of investigations, banking operations, government regulations, and account reconcilement.
Strong knowledge of SAR requirements and understanding of federal regulations pertaining to the Bank Secrecy Act.
Cyber Fraud knowledge and experience required.
Presentation and public speaking skills required.
Excellent problem solving and analytical skills required.
Excellent verbal/written and written communication skills required to interact with all levels of Bank personnel and outside contacts.
Experience using Microsoft Word, Excel and Access required
Ability to proofread and edit documents.
Excellent organizational, time management and analytical skills.
Excellent leadership skills, able to interact effectively with management and staff at all levels.
Represents basic qualifications of the position. To be considered for this position you must at least meet the basic qualifications.
City National Bank is an Equal Opportunity Employer -- Minorities/Females/Individuals with Disabilities/Veterans.
Note: This preceding job description has been designed to indicate the general nature and level of work performed by employees within this classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of employees assigned to this job.
Note: Candidates should be advised that City National Bank does not pay interviewee travel expenses or relocation expenses for candidates who are hired unless previously agreed.
Equal Opportunity Empl
Desktop Fraud Investigator
CL - Claims
Estimated Travel Percentage (%): No Travel
Relocation Provided: No
AIG Europe Limited
The Fraud Investigator (Desktop) is responsible for all aspects of the investigation process to include creation of investigation plans, identification and assignment of relevant enquiries and reporting on findings. The investigator will provide assistance to the claims adjuster in progressing the claim and will leverage knowledge and expertise to ensure that the fraud risk to AIG is minimised. Accountabilities for the role:
As an Insurance Fraud Investigator you will be responsible for investigating suspicious insurance claims or suspicious insurance related activities covering all lines of business involving claimants, brokers, lawyers, medical providers, etc, to support the Claims organisation.
Ability to manage all aspects of the claims investigation, to include analysing facts on issues in question, thorough review of interviews and statements of witnesses, employers, claimants and other relevant witnesses.
Obtaining and preserving physical and documentary evidence to support investigations.
Coordinating necessary investigative techniques and resources, such as fieldwork through internal or external field resources, cognitive interviews, etc. and ensuring quality is accurate, timely and appropriate on all cases.
Producing reports based on evidential findings, providing adjusters with the information required to progress the claim as appropriate.
Handling caseload across relevant jurisdictions while ensuring all tasks are completed properly.
Testifying and presenting evidence at administrative and criminal court proceedings as required.
Establishing and maintaining professional working relationships with insured's, lawyers, corporate employees, vendors, police and relevant fraud bodies.
Completing targeted claims reviews for all lines of business within AIG as assigned. This includes analysis, documentation of results and suggestions for improvement.
Accurately identify and record all financial impact for cases worked in the case management system
Assisting GIS and local management as appropriate in ensuring key deliverables and business objectives are met.
Awareness of, and adherence to, local laws regarding techniques used for information gathering in countries where operating.
Provide intelligence feedback to claims and underwriting departments regarding loss trends and opportunities for future fraud mitigation.
Experience & Qualifications Required:
Knowledge of criminal and civil justice systems
Ability to manage workflow to create and pursue leads that would support a fraud case
Ability to work to tight timelines when necessary
Demonstrable investigative-related experience essential, preferably in an insurance claims dept
Relevant Third Degree level preferred
PC skills and experience with various database search systems
Advanced knowledge of 'Theft and Fraud Offences Act' and 'Civil Courts & Liability Act' and their application in insurance fraud
Understanding of Data Protection Act and other compliance legislation.
It has been and will continue to be the policy of American International Group, Inc., its subsidiaries and affiliates to be an Equal Opportunity Employer. We provide equal opportunity to all qualified individuals regardless of race, color, religion, age, gender, gender expression, national origin, veteran status, disability or any other legally protected categories.
At AIG, we believe that diversity and inclusion are critical to our future and our mission – creating a foundation for a creative workplace that leads to innovation, growth, and profitability. Through a wide variety of programs and initiatives, we invest in each employee, seeking to ensure that our people are not only respected as individuals, but also truly valued for their unique perspectives
Fraud Investigator - Parks & Resorts
This position will support the E-Commerce department as it relates to profit protection thru the E-Commerce Fraud Prevention program.
Review online transactions for potential fraud
Must be able to interface with guests and operations team during investigative process
Assist the E-Commerce LP and Finance teams by providing evidence for the resolution of Chargebacks
Assist with the maintenance of detailed records, analyzing trends and communicate potential risks as they arise
Stay abreast of emerging trends and industry best practices for online fraud detection and prevention
Other projects or responsibilities as assigned
High School Diploma or equivalent
Minimum 2 years fraud analyst or relevant work experience
Knowledge of payment processing and credit card industry regulations
Flexible schedule to meet the needs of a 24/7, 365 day a year operation
Some travel may be required
Must be able to maintain confidentiality
Able to work outdoors in varying weather conditions and walking/traveling to multiple venues throughout the day
Interested candidates must submit a resume/CV through nbcunicareers.com to be considered
Must be willing to work in Universal City, CA
Must have unrestricted work authorization to work in the United States
Must be 18+ years or older
Must be covered by Solutions, NBCU's Alternative Dispute Resolution Program
Detail oriented with strong organization and communication skills
Strong verbal and written communication skills
Strong analytical skills and the ability to handle multiple tasks at the same time
Ability to work independently and in a team environment while managing time effectively
Customer service background
Loss Prevention background preferred
Thorough knowledge of MS Excel, Word and PowerPoint
Fraud Prevention And Recovery Investigator (3331-703)
Founded in 1994, Digital River is recognized as a leading global provider of Commerce-as-a-Service solutions. Companies of all sizes rely on Digital River's multi-tenant, SaaS commerce, payments and marketing services to manage and grow their online businesses. Digital River has helped companies process more than $30 billion in online transactions, connecting B2B and B2C digital products and cloud service companies as well as branded manufacturers with buyers across multiple devices and channels, and nearly every country in the world.
We are fortunate at Digital River to work with some of the e-commerce industry's brightest talent. We have professionals on the ground in nearly every region of the world, including North America, Europe, Asia and Australia. Our employees are experts in e-commerce, e-marketing, creative site design and merchandising, global tax and compliance laws, fraud prevention, international payments and more. To attract and retain the best-of-the-best, we invest a great deal of time and effort in creating a community that people want to be part of and high performance culture where they can grow.
Momentum is what we have and growth is our plan. We are looking for people who are energized by making an impact, having autonomy in their work and who want the ability to look back at what they have accomplished and say "wow." If you are someone who loves being part of a team that is more like a family and likes to work for companies at the top of their game, join Digital River.
We are seeking a Fraud Investigator in our Minnetonka, MN office. The Fraud Investigator is responsible for performing analysis of transactions, via real-time queues and after-the-fact reports, to identify unauthorized credit card and account use. The Fraud Investigator maintains production workload levels to meet the demands and of our CE, software and gaming clients. The Fraud Investigator reviews and responds to suspected fraudulent service requests, queues, and transaction records to identify potentially fraudulent transactions or accounts. The Fraud Investigator will identify problems and issues by performing relevant research using the appropriate tools and following established procedures. The Fraud Investigator utilizes custom and standard software programs and applications as well as manual review to analyze transactional and customer record for fraud.
What You'll Do:
Fraud Prevention and Detection
Monitors numerous real-time queues and analyzes high-risk transactions using a variety of proprietary and third party data sources and techniques which may include outbound calls.
Determines if transactions are fraudulent and should be canceled and refunded, are legitimate and should be processed and fulfilled.
Coordinates with fulfillment partners to recall fraudulent transactions that are in transit.
Manages inbound customer service escalations via email.
Reviews historical transactions looking for processes defects such as chargebacks or insults and attempts to cross-link the transactions to larger trends.
What You'll Need to Succeed:
High school diploma/GED or equivalent, 1 - 3 years fraud prevention experience in a customer facing service type of environment
Understanding of online ecommerce, payments, and computer best practices and methods
Written and verbal communication skills, analytical skills, and problem solving skills
Self-motivated and able to work independently and within a team
Problem solving and troubleshooting skills, and ability to multitask on competing priorities
Ability to perform to established standards for customer service, and resolves complex issues with little or no supervision or direction
Ability to perform duties independently with moderate supervision
Ability to establish and maintain effective working relationships with those contacted in the course of work
Previous experience in an Internet-based company, and especially if within the fraud area
WHY DIGITAL RIVER:
Digital River provides numerous benefits to our employees. On-site benefits include:
Cafeteria and Starbucks Coffee
Workout facility and group fitness classes
Monthly bring-your-dog-to-work days
Recreation area with foosball, pinball, and table tennis
Massage therapist and chiropractor
Pond hockey games in the beautiful Digital River backyard
Friday social hour
Casual work environment with friendly faces
Other benefits include:
Digital River In Action, an employee volunteer organization aiding those in need in the Twin Cities area
The Green Team, a resource acting in support of an environmentally conscious workforce
Competitive benefits package to full time employees:
Medical-dental-vision and life insurance
Paid short and long-term disability
Holiday and vacation days
Digital River supports and embraces a diverse workforce as an Equal Employment Opportunity Employer.
RESPECT | INTEGRITY | CUSTOMER CENTRICITY | INNOVATION | GLOBAL PERSPECTIVE | ACCOUNTABILITY
Pharmacy Fraud Investigator
Arizona Health Care Cost Containment System
Accountability, Community, Innovation, Leadership, Passion, Quality, Respect, Teamwork
Pharmacy Fraud Investigator
First Review 2/26/18
This position will remain open until filled
Arizona Health Care Cost Containment System (AHCCCS), Arizona's Medicaid Agency, is driven by the passion to deliver comprehensive and cost effective health care to Arizonans in need. AHCCCS is nationally acclaimed as a model for other Medicaid programs and recipient of multiple awards for excellence in workplace effectiveness and flexibility. Visit our careers page to learn more about AHCCCS. Use your skills to benefit others; join the AHCCCS Team!
The Office of Inspector General is looking for a highly motivated individual to join our team as a Pharmacy Fraud Investigator. Pharmacy, Investigations Unit is responsible for investigating allegations of Medicaid Pharmacy fraud. Compiles detailed reports of investigation for referral to the Attorney General's Office for potential prosecution and recovery of misspent State dollars. Major duties and responsibilities include but are not limited to:
Complete required health care fraud audits regarding member and provider prescription and/or pharmaceutical allegations to establish if program violations have occurred through billing, health care records, financial documentation, access to mainframe computer systems to include, but not limited to AHCCCS, DES, MVD and DPS.
Research Policy, Contracts, Laws, Procedures and other documentation as it relates to health care fraud allegations,
Develop over-payment report: losses to the Medicaid Program through diligent research and review in order to present the evidence to the legal authorities for prosecution.
Communicate effectively with AHCCCS members, providers, and contractors occasionally under adverse arid threatening circumstances. Authority to draft and serve subpoenas and take sworn statements.
Conduct interviews and obtain written statements from AHCCCS members, providers, and clients to determine if fraudulent activities have occurred.
Prepare written reports for use in administrative or legal proceedings.
May be assigned cases not related to pharmaceutical or pharmacy related allegations.
Participate in Arizona Management System (AMS) and LEAN processes.
Knowledge Of: Law Enforcement processes and protocols, Basic investigative techniques, Proper methods of interviewing suspects, witnesses and victims, and of the rules regarding the admissibility of statements, admissions and confessions.
Basic knowledge of pharmaceuticals and/or pharmacy operations
Thorough knowledge of HIPAA and the rules pertaining to the sharing of investigative information, Relevant statutes and laws pertaining to the investigation of Medicaid fraud, waste and abuse, Claims processing, procedures, financing and operations for FFS and MCO, Preparation of computerized spreadsheets which support audit findings, Income and resource requirements for eligibility for each of these varied programs, Arizona Revised Statutes, State Personnel Rules.
Skilled in: Computing, summarizing, and aggregating qualitative and quantitative data in an accurate and timely manner, Investigative methods, techniques and approaches necessary to plan and conduct program compliance audits, Interpreting and applying federal and state laws, rules, regulations, and procedures, Organizing, documenting and preparing investigative reports, Written and verbal communications.
Ability to Prepare written documentation in a clear and concise manner.
Must possess an Arizona State Driver's License in good standing with fewer than 6 points.
- Two or more years of responsible investigative experience preferably in government, healthcare, law enforcement or insurance. Degree in Criminal Justice or related field or a Certified Fraud Examiner (CFE), or Certified Professional Coder (CPC) or other related Certification
At AHCCCS, we promote the importance of work/life balance by offering workplace flexibility and a variety of learning and career development opportunities. Among the many benefits of a career with the State of Arizona, there are 10 paid holidays per year, accrual of sick and annual leave, affordable medical benefits and participation in the Arizona State Retirement Plan. Click here to learn more about benefits.
Arizona State Government is an EOE/ADA Reasonable Accommodation Employer.
All newly hired employees will be subject to E-Verify Employment Eligibility Verification.
Click the APPLY NOW button to submit your application.
For technical assistance, email [email protected] or call 602-542-4700.
Healthcare Fraud Investigator - Remote
NCI: As the Healthcare Fraud Investigator - Remote ( Program Integrity Analyst ) supporting AdvanceMed,you will perform in-depth evaluation of potential fraud investigations and develops investigations that involve monetary losses, sensitive issues, meet criteria for referral to law enforcement, or the imposition of administrative actions. In assuming this position, you will be a critical contributor to meeting NCI AdvanceMed's mission: To provide services to our clients that exceed their expectations and contribute to improved healthcare delivery by identifying and eliminating fraud, waste and abuse.
NCI is always seeking talent and although this position is contingent upon an open position, we encourage you to apply. We anticipate hiring for these positions in Summer 2017, pending contract award.
Highlights of Responsibilities:
Conducts independent investigations resulting from the discovery of situations that potentially involve fraud, waste, or abuse. Utilizes data analysis techniques to detect aberrancies in Medicare claims data, and proactively seeks out and develops leads received from a variety of sources (e.g., CMS, OIG, fraud alerts).
Completes written referrals to law enforcement and takes steps to initiate recoupment of overpaid monies.
Responds to requests for information from law enforcement.
Maintains cases that were referred to law enforcement.
Maintains the "Do not pursue" list.
Reviews information contained in standard claims processing system files (e.g., claims history, provider files) to determine provider billing patterns and to detect potential fraudulent or abusive billing practices or vulnerabilities in Medicare policies and initiates appropriate action.
Makes potential fraud determinations by utilizing a variety of sources such as the UPIC's internal guidelines, Medicare provider manuals, Medicare regulations, and the Social Security Act.
Develops and prepares potential Fraud Alerts and Program Vulnerabilities for submission to CMS; shares information on current fraud investigations with other Medicare contractors, law enforcement, and other applicable stakeholders.
Reviews and responds to requests for information from Medicare stakeholders as assigned; pursues applicable administrative actions during investigation/case development (e.g., payment suspensions, civil monetary penalties, requests for exclusion, etc.)
Participates in onsite audits in conjunction with investigation development.
Provides support of cases at hearing/appeal and ALJ level.
Maintains chain of custody on all documents and follows all confidentiality and security guidelines.
Compiles and maintains various documentation and other reporting requirements.
High school diploma, with preference given to those candidates who have successfully completed college or technical degree programs related to the position (e.g., criminal justice, statistics, data analysis, etc.)
At least one (1) year of experience in program integrity investigation/detection or a related field that demonstrates expertise in reviewing, analyzing/developing information, and making appropriate decisions.
Must have and maintain a valid driver's license issued by the state of residence.
Preferred Education and Experience:
Knowledge of statistics, data analysis techniques, and PC skills.
Experience in fraud detection and investigation within the Medicare program.
Previous law enforcement experience, especially in the field of investigations.
Certified Fraud Examiners (CFE) designation.
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It is the policy of NCI to provide equal opportunity in recruiting, hiring, training, and promoting individuals in all job categories without regard to race, color, religion, national origin, gender, age, disability, genetic information, veteran status, sexual orientation, gender identity, or any other protected class or category as may be defined by federal, state, or local laws or regulations. In addition, we affirm that all compensation, benefits, company-sponsored training, educational assistance, social, and recreational programs are administered without regard to race, color, religion, national origin, gender, age, disability, genetic information, veteran status, sexual orientation, or gender identity. It is our firm intent to support equal employment opportunity and affirmative action in keeping with applicable federal, state, and local laws and regulations.
The information above has been designed to indicate the general nature and level of work performed by employees within the classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of employees assigned to this position.
Medical Fraud Investigator
Primary Job Duties & Responsibilities
Analyzes and summarizes highly technical information related to multiple complex case investigations with regional and national implications. Conducts thorough and timely complex field investigations while managing resources with a focus on uncovering potential fraudulent medical aspects of a claim.
Applies the techniques of critical thinking to prioritizes and develop medical investigations that have complex allegations and/or significantly financial impact to multiple claims and/or organized ring activity spanning across multiple lines of business and potentially across several states. Makes key decisions regarding the structure and organization of major medical case investigations involving multiple claims and/or organized ring activity with regional and national implications. Provides exceptional customer service by maintaining contact with business partners, customers and external resources throughout the life of each investigation.
Acts as a liaison with local/state/federal law enforcement personnel, industry advocates and other companies Serves as the subject matter expert (liaison) on medical fraud to business and industry partners. Applies rules of evidence; recognizes evidence and determines its value to specific claim, evidence collection and interpretation. Establishes and maintains a professional network in the medical anti-fraud industry (e.g., National Insurance Crime Bureau, National Healthcare Anti-Fraud Association, local fraud agencies, law enforcement, etc.). Identifies cases for potential insurance fraud prosecution and submits questionable claims to the National Insurance Crime Bureau.
Analyzes, transforms and conveys emerging trends in the medical fraud arena into actionable investigative strategies. Proactively collaborates with supporting business partners (e.g., claim, legal, nurses, analytical unit etc.) to implement anti-fraud and medical defense strategies. Responsible for strengthening technical capabilities within claim to identify potential medical fraud.
Assists in the identification and communication of trends to manager of the program. Conducts post-mortems on cases closed or status reviews of cases in progress. Prepares and conducts technical training in detecting and applying techniques to multiple medical complex cases.
Testifies to findings. Other duties as assigned.
Job Specific & Technical Skills & Competencies
Analytical skills and ability to make deductions; logical and sequential thinker: Advanced. Analytical and problem solving skills to use and interpret information and facts as well as apply critical techniques to investigative process: Advanced.
Effective business communication skills (Written & Verbal): Advanced. Computer literate; database, Internet and social media proficient: Advanced. Interviewing skills: Advanced.
Computer literate; database and internet emerging social media use/search proficiency: Advanced. Conflict management skills to deal with crisis situations, hostile witnesses, etc.: Advanced. Must be a self-motivated individual: Intermediate.
Excels at working independently, while making decisions to successfully pursue medical insurance fraud through establishing significant facts while preserving material that leads to the resolution of the investigation: Intermediate. Knowledge of available resources (internal and external) to assist in investigations: Advanced. Working level knowledge of insurance and claim operations, Commercial Lines, Personal Lines, and Workers Compensation insurance products: Intermediate.
Time management and accurate record keeping: Intermediate. Effective business communication skills (Written & Verbal): Advanced. Strong case management skills and the ability to manage your own work independently: Intermediate.
Adapt to changes in process and shifting priorities: Intermediate. Must take ownership/initiative; significant planning and goal setting skills required: Intermediate. Presentation and training skills: Intermediate.
Understanding of claim best practices: Intermediate. Leadership, including delegation and ability to get work done through others: Intermediate. Influence and conflict management skills: Intermediate.
Under general supervision, this position is responsible for conducting medical investigations (locally or nationally) in multiple lines of business including: Auto, General Liability and Workers Compensation.
Provides investigative expertise to detect and deter medical fraud and create awareness in order to limit exposure to the company and our customers. Focus is directed towards multiple complex case investigations with regional and national implications. This job does not manage staff.
Education, Work Experience & Knowledge
Bachelors degree preferred.
Operates standard office equipment: Frequently. Sitting (can stand at will): Continuously.
Lifting items up to 20 pounds: Occasionally. Use of Keyboards, Sporadic 10-Key: Frequently. Driving: Frequently.
A minimum five years of medical investigations experience or a minimum of five years medical experience required. Valid driver's license required.
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