Job Description

Program Overview

Performs data analysis, investigation, and medical review to detect, prevent, deter, reduce, and make referrals to recover fraud, waste, and abuse in Medicare and Medicaid programs.

About The Role

SafeGuard Services (SGS), a subsidiary of Peraton, performs data analysis, investigation, and medical review to detect, prevent, deter, reduce, and make referrals to recover fraud, waste, and abuse.

We are looking to add a Fraud Investigator to our SGS team of talented professionals.

What you'll do:

The Fraud Investigator is expected to primarily focus on conducting healthcare provider site verification visits in the South Florida region and to secondarily perform high level complex investigations of medical professional service providers and develop cases for future action, including referral to law enforcement, education, over payment recovery and other administrative actions.  Will work with internal resources and external agencies to develop cases and corrective actions as well as respond to requests for data and support.  

• Investigator will focus on conducting healthcare provider site verification visits to ensure providers are in operational status.
• Investigator will be able to draft appropriate correspondence documenting those visits as part of active investigations, to include taking photographs and making detailed observations that will assist in making these determinations.
• Investigator uses good judgment and may work independently with minimum supervision and direction.
• The investigator also may work as part of an investigative team and assist investigators in determining appropriate administrative actions, 
• Investigator handles additional case investigative assignments during site verification visit downtime; organizes and analyzes complex evidentiary patterns; interviews and obtains statements from witnesses and others.
• Investigators may also be required to complete investigative reports that apply regulations or rules to the program(s) affected by the behavior being investigated. There may also be times when the investigator will need to apply federal or state laws.
• Investigators are expected to research and understand the relevant offenses being investigated; conduct efficient and effective investigations concerning those alleged offenses and detect or verify suspected violations; obtain information and evidence by observation, record examination, and interview.
• Investigators then analyze the results of the investigation to ascertain if the allegations have been corroborated and work with others to determine the appropriate steps that need to be taken to address the issues.
• Investigators are expected to have strong interviewing skills, and be skilled at developing rapport with beneficiaries, complainants, and/or providers.
• As part of an investigation, the investigator will need to prepare correspondence; be objective and accurate and communicate with others with tact.
• There may be times when investigators need to react to unplanned situations, be flexible in planning their activities and adopt effective courses of action.
• As investigators will be working with health privacy information, they also must maintain confidentiality and understand all the laws, rules and regulations concerning health privacy.
• Be available to travel to conduct provider site verifications and provider onsite visits, as needed.  Rental Car provided and site verifications throughout Florida with a high concentration in Miami-Dade, Broward, West Palm Beach and Collier counties.
• Position will be onsite at Miramar, FL

Qualifications

Basic Qualifications:

• 4 years with AS/AA; 2 years with BS/BA; 0 years with MS/MA; 6 years with no degree
• Investigative experience
• Strong investigative and interview skills
• Strong communication and organization skills
• Strong PC knowledge and skills
• U.S. citizenship required
• Position will be onsite at Miramar, FL

Desirable Qualifications:

The most competitive candidates will have:

• Strong background in investigations and in conducting interviews to support investigations
• Experience in reviewing claims for technical requirements, performing medical review, and/or developing fraud cases
• Knowledge of investigative practices regarding healthcare providers.
• Knowledge of Medicare and/or Medicaid programs and the rules, regulations, policies and procedures
• Background in evaluating, reviewing and analyzing medical claims and records
• Ability to learn and operate a variety of data systems, equipment and tools used in investigations

Essential Functions:

• This position may require the incumbent to appear in court to testify about work findings.
• Ability to perform research and draw conclusions
• Ability to present issues of concern, citing regulatory violations, alleging schemes or scams to defraud the Government
• Ability to organize a case file, accurately and thoroughly document all steps taken
• Ability to compose correspondence, reports and referral summary letters
• Ability to educate providers, provider associations, law enforcement, other contractors and beneficiary advocacy groups on program safeguard matters
• Ability to communicate effectively, internally and externally
• Ability to effectively conduct interviews of beneficiaries, complainants, and/or providers.
• Ability to interpret laws and regulations
• Ability to handle confidential material.
• Ability to report work activity on a timely basis.
• Ability to work independently and as a member of a team to deliver high quality work
• Ability to attend travel extensively within the South Florida area to conduct site verification visits

SCA / Union / Intern Rate or Range

Details

Target Salary Range: $66,000 - $106,000. This represents the typical salary range for this position. Salary is determined by various factors, including but not limited to, the scope and responsibilities of the position, the individual’s experience, education, knowledge, skills, and competencies, as well as geographic location and business and contract considerations. Depending on the position, employees may be eligible for overtime, shift differential, and a discretionary bonus in addition to base pay.

EEO: Equal opportunity employer, including disability and protected veterans, or other characteristics protected by law.

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