Fraud Investigator

Fraud Investigator
Posting Date:
Job Number:
Anaheim, CA
Security Clearance Status:
Not Applicable
Security Clearance Type:
NACI HSPD-12 (Background Investigation)
US Citizenship Required:
Job Level:
Individual Contributor
Employment Status:
Regular Full-Time
Designated a 2016 Military Friendly? Employer
NCI: As the Fraud Investigator ( Program Integrity Analyst ), you will perform in-depth evaluation of potential fraud investigations and develops investigations that involve monetary losses, sensitive issues, meet criteria for referral to law enforcement, or the imposition of administrative actions. In assuming this position, you will be a critical contributor to meeting NCI's mission: To deliver innovative, cost-effective solutions and services that enable our customers to rapidly adapt to dynamic environments. NCI is always seeking talent and although this position is contingent upon an open position, we encourage you to apply. Highlights of Responsibilities:
+ Conducts independent investigations resulting from the discovery of situations that potentially involve fraud, waste, or abuse. Utilizes data analysis techniques to detect aberrancies in Medicare claims data, and proactively seeks out and develops leads received from a variety of sources (e.g., CMS, OIG, fraud alerts).
+ Completes written referrals to law enforcement and takes steps to initiate recoupment of overpaid monies.
+ Responds to requests for information from law enforcement. Maintains cases that were referred to law enforcement. Maintains the "Do not pursue"? list.
+ Reviews information contained in standard claims processing system files (e.g., claims history, provider files) to determine provider billing patterns and to detect potential fraudulent or abusive billing practices or vulnerabilities in Medicare policies and initiates appropriate action.
+ Makes potential fraud determinations by utilizing a variety of sources such as the UPIC's internal guidelines, Medicare provider manuals, Medicare regulations, and the Social Security Act.
+ Develops and prepares potential Fraud Alerts and Program Vulnerabilities for submission to CMS; shares information on current fraud investigations with other Medicare contractors, law enforcement, and other applicable stakeholders.
+ Reviews and responds to requests for information from Medicare stakeholders as assigned; pursues applicable administrative actions during investigation/case development (e.g., payment suspensions, civil monetary penalties, requests for exclusion, etc.)
+ Participates in onsite audits in conjunction with investigation development. Provides support of cases at hearing/appeal and ALJ level. Maintains chain of custody on all documents and follows all confidentiality and security guidelines.
+ Compiles and maintains various documentation and other reporting requirements.
+ High school diploma, with preference given to those candidates who have successfully completed college or technical degree programs related to the position (e.g., criminal justice, statistics, data analysis, etc.)
+ At least one (1) year of experience in program integrity investigation/detection or a related field that demonstrates expertise in reviewing, analyzing/developing information, and making appropriate decisions.
+ Must have and maintain a valid driver's license issued by the state of residence.
Preferred Education and Experience:
+ Knowledge of statistics, data analysis techniques, and PC skills.
+ Experience in fraud detection and investigation within the Medicare program.
+ Previous law enforcement experience, especially in the field of investigations.
+ Certified Fraud Examiners (CFE) designation.
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It is the policy of NCI to provide equal opportunity in recruiting, hiring, training, and promoting individuals in all job categories without regard to race, color, religion, national origin, gender, age, disability, genetic information, veteran status, sexual orientation, gender identity, or any other protected class or category as may be defined by federal, state, or local laws or regulations. In addition, we affirm that all compensation, benefits, company-sponsored training, educational assistance, social, and recreational programs are administered without regard to race, color, religion, national origin, gender, age, disability, genetic information, veteran status, sexual orientation, or gender identity. It is our firm intent to support equal employment opportunity and affirmative action in keeping with applicable federal, state, and local laws and regulations.
The information above has been designed to indicate the general nature and level of work performed by employees within the classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of employees assigned to this position. d19a90aba656420498300c9884a3a997

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