The Investigator is an integral position within the Plan. This position is responsible for the effective and compliant oversight of the fraud, waste and abuse (FWA) program in accordance with the Plan contract with CMS and the State. The position is responsible to ensure compliance with federal, state and local laws, regulations and policies related to FWA. The Investigator is responsible for conducting investigations on compliance and FWA related matters, investigations may include potential compliance policy of federal healthcare law-related matters, including Anti-Kickback Statute (AKS), False Claims Act (FCA), and other laws and regulations related to healthcare compliance. The Investigator will coordinate with departments, including legal and human resources, to handle all aspects of investigations, including gathering relevant documentation, conducting interviews, documenting investigations, and recommending corrective action as necessary. The role also includes both written and oral investigations updates to multiple various stakeholders, including senior leadership.
Essential Duties and Responsibilities include the following:
- Conduct investigations across business areas. Investigations process may include research, data analysis, process analysis, interviews, follow-up, and documentation.
- Carefully analyze factual findings in order to determine proper case disposition and follow up.
- Prioritize and manage a significant caseload in a timely fashion.
- Maintain detailed case files and accurately summarize investigative findings and conclusions.
- Regularly interact with colleagues in various departments across the organization to conduct investigations and implement corrective action where necessary.
- Provide regular written and verbal updates to senior leadership.
- Assist or lead special projects related to the investigative function, as necessary.
- Report to federal and/or state law enforcement as appropriate
- Report to state insurance divisions based on guidance
- Oversee the development and monitoring of corrective action plans coordinate validation of any corrective actions to ensure remediation is completed;
- Updates policies and procedures needed.
- Adhere to established corporate policies and procedures
- Perform other duties, as necessary, to meet corporate objectives
- Travel as required
To 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 accommodations may be made to enable individuals with disabilities to perform the essential functions.
Education and/or Experience:
- Bachelor’s degree in Health Care or other related field
- Solid experience in managed care with a minimum of five (5) years government, health care, pharmacy benefit management, compliance, FWA or quality profession (equivalent combination of education and experience considered.)
- Knowledge of federal healthcare laws, regulations and guidance.
- Prior experience in conducting investigations, specifically in healthcare
- Solid knowledge of CMS, Medicare Part C and Part D regulations.
- Ability to work independently, manage multiple projects and meet scheduled deadlines.
- Ability to identify root cause issues and ensure appropriate corrective actions.
- Strong analytical and organizational skills with attention to detail.
- Proficiency in applying and interpreting rules associated with Medicare regulations.
- Excellent written and verbal communication skills required
- Advanced degree or certification in compliance or FWA discipline preferred
- Must work well under tight timelines and adapt quickly to change in a fast-paced, team-oriented, and high-growth environment.