Senior Healthcare Fraud Investigator

Senior Healthcare 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 Senior Fraud Investigator ( Program Integrity Analyst ), you will perform in-depth evaluation of potential fraud cases and develop complex investigations that involve high dollar amounts, sensitive issues, or that otherwise meet criteria for referral to OIG, and prepare those cases for referral to OIG. You will provide peer leadership for Program Integrity Analysts through mentoring, on-site audit leadership, and hands-on training of investigative techniques. 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 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.
+ 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.
+ Reviews, analyzes, develops and prepares potential Fraud Alerts and submits these to CMS for consideration for publication. Shares information on current fraud investigations with other Medicare contractors and alerts the CMS COTR to cases being developed in other regions.
+ Responds to requests for information from law enforcement. Maintains cases that were referred to law enforcement. Maintains the 'Do not pursue' list.
+ Reviews requests for data received from the OIG, DOJ, etc., Makes initial determinations regarding the UPIC's ability to comply, communicates with the requesting agency and the CMS COTR as necessary, and prepares the material for transmittal.
+ Ensures that the UPIC maintains effective communication and coordination with appropriate law enforcement agencies, as well as other government federal and state agencies and organizations involved in combating fraud and abuse.
+ Prepares, develops, and participates in provider, beneficiary, law enforcement, or staff training as related to Medicare Fraud and Abuse issues.
+ Provides leadership and participates in onsite audits in conjunction with investigation development. Provides support to Fraud Analysts in the preparation and development of tasks related to onsite audits. Supports all assigned tasks relating to hearing/appeal and ALJ issues. Maintains chain of custody on all documents and follows all confidentiality and security guidelines in accordance with CMS and UPIC requirements.
+ Compiles and maintains various documentation and other reporting requirements as required.
+ High school diploma, with preference given to those candidates who have successfully completed college or technical courses related to the position (i.e., law enforcement investigation, statistics, data analysis) and have met all requirements to be designated a Certified Fraud Examiner.
+ At least three (3) years of experience in program integrity investigation/detection or a related field that demonstrates expertise in reviewing, analyzing, and 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 PSC skills.
+ Certified Fraud Examiners (CFE) designation.
+ At least two (2) years of experience in project management.
+ Previous experience investigating healthcare related fraud.
+ Experience testifying in state and/or federal court is also a plus.
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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. eb91ca2f596d4364916e6d65e2a88d24

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