The Investigations Specialist receives, researches, and reports on allegations of potential or actual fraud, waste, and abuse (FWA). In addition, the Exception Specialist is required to identify and monitor utilization and billing trends that may indicate FWA. The Investigations Specialist leverages internal and external resources, including communications with members, facilities, clients, law enforcement, and other parties, to fully investigate potential or actual FWA.
This is a temporary assignment on the Investigations Team. In this developmental opportunity, you can expect to be in the role from 6-12 months.
ESSENTIAL FUNCTIONS
Advises management team on issues relating to FWA investigations processes
Processes faxes, mail, email, and web requests (inbound and outbound) related to allegations or patterns indicating potential or actual FWA
Reports to management team bona fide allegations of potential or actual FWA
Assists management team with reports to and regular/ad hoc status calls with clients or law enforcement regarding allegations or patterns indicating potential or actual FWA
Collaborates with Network Services personnel to fulfill internal, client, or law enforcement requests for field investigations involving allegations or patterns indicating potential or actual FWA
Provide outreach and education to members, facilities, clients, law enforcement, and company personnel regarding FWA, as needed
Additional duties as assigned, including assisting and performing functions for other departments
POSITION QUALIFICATIONS
High School Graduate or General Education Degree / Graduate Equivalency Degree (GED)
2 to 5 years' contact center or front office medical facility experience is strongly preferred
Excellent customer service and people skills; must be able to work independently and with teams
Ability to quickly learn new technology and processes
Must be able to understand and follow complex instructions
Read, write, speak, and understand English fluently
We value our team members and realize the importance of benefits for you and your family.
We offer a comprehensive benefits package to include the following:
Medical, Dental, and Vision insurance
Employer Paid Basic Life Insurance and AD&D
Voluntary Life Insurance (Employee/Spouse/Child)
Health Care and Dependent Care Flexible Spending Accounts
Pre-Tax and Post --Tax Commuter and Parking Benefits
401(k) Retirement Savings Plan with Company Match
Paid Time Off
Paid Parental Leave
Short-Term and Long-Term Disability
Tuition Reimbursement
Employee Discounts (retail, hotel, food, restaurants, car rental and much more!!)
