Job Description

Remote - Special Investigative Unit Investigator

Pride Health is hiring a Special Investigative Unit Investigator for one of its clients in Michigan.

This is a 12-week contract with a possible extension, with competitive pay and benefits.

This position is remote, but candidates MUST be in Eastern or Central time zones.

Location – Remote (Troy, Michigan - 48083)

Pay range - $40 - $44 per hour.

Length of assignment – 12 weeks (With possible extension)

Shift – 8a-5p Eastern Mon – Fri.

Job Summary

Special Investigative Unit (SIU) Investigator responsible for investigating reports of non-compliance with corporate and regulatory policies, including reports of fraud, waste, or abuse. As a member of the SIU team, the investigator recommends methodologies that help prevent improper conduct by identifying, assessing, and correcting areas of noncompliance in risk areas in an effective manner. Utilize monitoring systems to track, remediate, and create reports, particularly from the data mining tool. Be responsible for all assigned investigations, follow-ups, and resolutions. Possess the judgement and discretion to handle cases that are sensitive and/or high profile, and the intellectual rigor and professional experience to work on complex cases that can be national in scope and involve intricate health care fraud schemes.

Job Duties

• Independently analyze public and HAP internal data and information to develop a preliminary assessment of facts to determine if a full investigation is warranted. Develop an investigative strategy and approach to complete the investigation.
• Assembles evidence and documentation to support successful adjudication, where appropriate.
• Conducts on-site audits of provider records, ensuring appropriateness of billing practices.
• Conduct interviews with providers, employees, members, and witnesses as part of the investigative process.
• Prepares complex investigative and audit reports with the ability to present investigation summaries that include metrics, trends, and schemes to various stakeholders, including enforcement agencies.
• Must be able to craft a well-organized referral explaining the alleged fraud in a fraud referral to regulators.
• Coordinates investigation with law enforcement authorities and regulatory agencies.
• Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas.
• Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed.
• Follows established guidelines/procedures.
• Ensure that the compliance department meets the required OIG effective compliance program elements by promptly responding to identified issues and concerns within the organization.
• Work independently and manage a caseload that includes investigations, identifying schemes, tracking, trending, and reporting instances of non-compliance.
• Respond to alleged violations of rules, regulations, policies, procedures, and Code of Conduct by evaluating or recommending the initiation of investigative procedures. Ensure policies and procedures are followed for the general operation of the compliance program and its related activities to prevent illegal, unethical, or improper conduct.
• Independently move an investigation to the next step in the investigative process with minimal assistance and errors. This includes from the opening to the final disposition.
• Independently develop new cases based on proactive data mining efforts.
• Respond to a complaint, take statements, document effectively, and identify any fraud, waste, or abuse.
• Identify patterns and trends to generate new investigative leads.
• Collaborative Skills: Demonstrates strong teamwork and collaboration abilities, effectively working with other investigators to achieve common goals and take responsibility for team outcomes while contributing to the overall success of the team.
• Adaptability: Shows flexibility in adapting to different roles and responsibilities within the team, contributing to various aspects of investigations as needed.
• Demonstrated experience with Managed Care products such as Medicare, Medicaid, ACA, and commercial insurance.
• Develop and facilitate training regarding Fraud Waste and Abuse requirements, the client’s Non-retaliation policy, Code of Conduct, and government program requirements.
• Perform other related duties as assigned.

Requirements

• Bachelor's Degree (Master's or Law degree preferred).
• CFE or AHFI certification.
• Minimum of 3 years of experience in healthcare, pharmacy technician, claims adjudication, medical billing/coding, nursing, or law enforcement.
• Previous experience working for a health insurance payer.
• Minimum of 2 years of experience conducting comprehensive investigations, preferably with interaction with state, federal, and local law enforcement agencies.
• Previous experience with the FACETs system.

Benefits

Pride Global offers eligible employees comprehensive healthcare coverage (medical, dental, and vision plans), supplemental coverage (accident insurance, critical illness insurance, and hospital indemnity), 401(k) retirement savings, life & disability insurance, an employee assistance program, legal support, auto, home insurance, pet insurance, and employee discounts with preferred vendors.

Equal Opportunity Employer

As a certified minority-owned business, Pride Global and its affiliates - including Russell Tobin, Pride Health, and Pride Now - are committed to creating a diverse environment and are proud to be an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, pregnancy, disability, age, veteran status, or other characteristics.

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