Job Description

Role: Fraud Investigator

Location: Boston, MA (Remote)

Type: Contract

Job Overview:

• The Investigator will be assigned to conduct pre-payment reviews of medical records for healthcare claims in one or more of the following areas:
• (1) Partial Hospitalization and Intensive Outpatient Programs;
• (2) Laboratory Testing; and/or
• (3) Durable Medical Equipment.
• The Investigator will work under the direction of an experienced pre-payment review investigator and work closely with other members of the SIU.
• Reviews are fast-paced and require the investigator to be organized and efficient in requesting records, reviewing documents, recommending outcomes, and coordinating claim dispositions (payment or denial) within the SIU and with internal business partners.

The Investigator will be responsible for the following:

• Drafting and issuing letters to providers requesting clinical records and other relevant documentation
• Utilizing case management systems to document case work, including correspondence, findings, and an investigative chronology
• Evaluating claims by applying Plan policies and procedures and generally accepted industry standards of practice.
• Preparing written summaries of findings, supported by evidence collected in the investigation
• Assisting in the preparing fraud referrals to other SIU investigative staff, regulatory agencies, and law enforcement, when appropriate
• Contacting members, providers, and other relevant parties to obtain additional information about assigned reviews

Qualifications:

• 1-3 year's related experience in health insurance fraud investigations, health insurance coding, provider relations, or another similar role
• Bachelor's degree
• Certified Fraud Examiner (CFE), Certified Professional Coder (CPC), or Accredited Health Care Fraud Investigator (AHFI) preferred
• Familiarity with Partial Hospitalization and Intensive Outpatient Programs, Laboratory Testing, and/or Durable Medical Equipment preferred

Skills:

• Demonstrated proficiency in Microsoft Word and Excel (including use of analytical tools such as Pivot Tables)
• Organization and time-management skills

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