Senior Fraud Investigator Job at TruBlu HR Solutions, Bellaire, TX

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  • TruBlu HR Solutions
  • Bellaire, TX

Job Description

Skills/Qualifications

  • HS diploma or GED or Bachelor’s degree
  • 8 years of experience in fraud, waste & abuse (FWA) investigations or special investigations unit (SIU) including 1 yr experience working with Medicaid
  • Must hold one of the following certifications :
  • CPA (Certified Public Accountant)
  • CFE (Certified Fraud Examiner)
  • AHFI (Accredited Health Care Fraud Investigator)
  • INT – POPC Intermediate Peace Officer Proficiency Certificate

  • Strong analytical and research skills.
  • Proficient in researching information and identifying information resources.
  • Exercises independent judgement and uses available resources and technology in developing evidence and supporting allegations of fraud, waste, and abuse.
  • Knowledge of medical terminology and/or experience with CPT codes, and ICD-9, ICD-10 coding.
  • Knowledge of suspected FWA trends and matters of interest to law enforcement and regulators.
  • Strong communication and customer service skills.

Job Duties

  • Coordinates with subcontractors on overseeing investigations of Fraud, Waste & Abuse (FWA).
  • Manages a large fraud investigation caseload and investigates allegations relating to potential health care fraud perpetrated by Medicaid and commercial providers, vendors, and enrollees.
  • Provides internal and external case updates on progression of investigations in coordination with SIU team members and other departments, including recommendations on further action and/or resolution, as needed.
  • Continually interfaces with members, vendors, pharmacies, providers and other third parties via telephone, e-mail, and on-site visits as needed to identify, further, and conclude ongoing investigations.
  • Implements processes and procedures to: prevent, detect, investigate and report FWA to appropriate regulatory agencies.
  • Provides inter-departmental input regarding controls for preventing and monitoring FWA issues.
  • Proactively identifies trends and aberrant activity to generate leads for FWA investigations.
  • Performs special assignments related to FWA as assigned by the Director of Controls and Compliance.

Job Tags

For subcontractor,

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