Applicants must live near Boise, ID. This position is responsible for
comprehensive management and ownership of fraud, waste and abuse investigations
including development and presentation of investigative results. This individual
carries out analytical and process management tasks with a high degree of
autonomy. This individual serves as a corporate resource on fraud, waste and
abuse issues and recommends cost containment projects with an emphasis on fraud
prevention. INVESTIGATIONS Prioritize, triage and manage workload to meet
internal performance metrics, regulatory and contractual requirements Use
independent judgment to create investigative work plans and develop case
strategies based upon analysis of referral data and contractual/regulatory
requirements Analyze data and select audit samples using various sampling
methodologies Plan and conduct desk audits, field audits and/or site visits
Collect and analyze information to evaluate facts and circumstances through an
extensive review of data from professional and facility providers, member data,
contractual relationships, payment policies, Medicaid/Medicare rules and
statutes, etc. Conduct research on medical policies and practices, provider
characteristics, and related topics Interview patients, providers, provider
staff, and other witnesses/experts Prepare correspondence Obtain and preserve
physical and documentary evidence to support investigations Maintain
comprehensive case files FRAUD, WASTE AND ABUSE DETECTION Triage and prioritize
leads from internal and external sources Use knowledge of healthcare coding
conventions, fraud schemes, and general areas of vulnerability, reimbursement
methodologies, and relevant laws to find suspicious patterns in claims data,
provider enrollment data, and other sources Remain up to date on published fraud
cases, schemes, investigative techniques and methodologies, and industry trends
PACKAGING OF FINDINGS AND RECOMMENDATIONS Organize data and prepare a written
summary of investigative steps, conclusions, recommendations with attention to
detail and a high level of accuracy Prepare clear and concise investigatory
reports to support findings of potential fraud, waste and abuse CASE RESOLUTION
Identify, communicate and recover losses as deemed appropriate Present case to
internal department(s), law enforcement and/or regulatory agencies Support legal
proceedings as needed, including testifying in court or working with law
enforcement personnel to prepare cases for civil or criminal actions Negotiate
settlement agreements with subjects and/or attorneys Assist in preparation,
execution, and follow-up of settlement agreement terms CUSTOMER INTERACTIONS
Make presentations to customers, prospects, conference audiences, and law
enforcement Collaborate, consult, and coordinate regularly with clients on the
status and direction of assignments Develop and maintain contacts/liaisons with
law enforcement, regulatory agencies, task force members, other company SIU
staff and external contacts involved in fraud investigation, detection and
prevention MISCELLANEOUS DUTIES Represent client at industry task force meetings
and meetings with regulatory agencies Measure and report performance metrics
Identify opportunities and make recommendations for reduction of exposure to
fraud, waste and abuse Consult on anti-fraud policies and procedures Other
duties as assigned The job duties listed above are representative and not
intended to be all-inclusive of what may be expected of an employee assigned to
this job. A leader may assign additional or other duties which would align with
the intent of this job, without revision to the job description. Other Job
Requirements Responsibilities Minimum of five years of experience in fraud
investigations, related behavioral or medical healthcare insurance experience in
claims, clinical, auditing, compliance, provider networks, management, or
project planning. Demonstrated abilities in time management and establishing
priorities. Strong listening and observation skills. Impeccable work ethic,
completely dependable, and proactive; a problem solver. Proven ability to
effectively handle cases of fraud and abuse in a discreet, confidential, and
professional manner. Demonstrated strategic and analytical thinking skills, with
ability to effectively communicate conclusions and recommendations to
management. Comprehensive, practical knowledge of complex and diverse fraud
investigative techniques and methodologies utilized in program audits.
Understanding of insurance terms and policy interpretation. Ability to work to
tight timelines when necessary. Works independently; collaborates well with
peers and customers. Demonstrated ability to manage and prioritize case load
with limited supervision. Strong computer skills consisting of Microsoft Excel,
Access, Outlook, Word, and Power Point. General Job Information Title SIU
Program Integrity Investigator - Remote (In Idaho) Grade 24 Work Experience -
Required Fraud Investigations Work Experience - Preferred Education - Required A
Combination of Education and Work Experience May Be Considered., Bachelor's
Education - Preferred License and Certifications - Required License and
Certifications - Preferred AHFI - Accredited Healthcare Fraud Investigator -
EnterpriseEnterprise, CFE - Certified Fraud Examiner - EnterpriseEnterprise, CPC
- Certified Professional Coder - EnterpriseEnterprise, LSSBB - Lean Six Sigma
Black Belt Certification - EnterpriseEnterprise, RN - Registered Nurse, State
and/or Compact State Licensure - Care MgmtCare Mgmt Salary Range Salary Minimum:
$58,440 Salary Maximum: $93,500 This information reflects the anticipated base
salary range for this position based on current national data. Minimums and
maximums may vary based on location. Actual pay will be adjusted based on an
individual's skills, experience, education, and other job-related factors
permitted by law. This position may be eligible for short-term incentives as
well as a comprehensive benefits package. Magellan offers a broad range of
health, life, voluntary and other benefits and perks that enhance your physical,
mental, emotional and financial wellbeing. Magellan Health, Inc. is proud to be
an Equal Opportunity Employer and a Tobacco-free workplace.
EOE/M/F/Vet/Disabled. Every employee must understand, comply with and attest to
the security responsibilities and security controls unique to their position;
and comply with all applicable legal, regulatory, and contractual requirements
and internal policies and procedures. Magellan is the employer of choice for
hard working people interested in making a difference in the health care
industry and in the communities where we work and live. Our strong culture of
caring is the common thread in both our business strategy and our work
environment. We value professional growth and development, total health and
wellness, rewards and recognition as well as employee unity. Magellan is a place
where you can thrive. Magellan is committed to providing equal employment
opportunities to employees and applicants for employment without regard to race,
color, creed, religion, sex, gender identity and expression, sexual orientation,
marital status, age, national origin, ancestry, citizenship, physical or mental
disability, disabled veteran or veteran of the Vietnam Era status, or any other
factors protected by law. Magellan is committed to meeting applicable Federal
labor and employment law posting requirements by providing necessary posters in
a format which is easily accessible and conspicuous to all applicants. Copies of
applicable posters are accessible by clicking here. Warning: Employment Scam It
has come to our attention that a false representative is contacting potential
candidates and offering them work at home positions with Magellan Health.
“Interviews” are conducted completely through email and the false job offer
includes the promise of a check to be issued to the candidate for the purposes
of setting up a home office. Please know that Magellan Health does not interview
any candidate through email, nor do we issue checks to candidates to set up home
offices. All of our available positions are posted on legitimate job boards and
our recruitment team directly contacts candidates should there be a fit. If you
suspect you are being contacted by a false representative of Magellan Health,
please call 410-953-2911
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