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GEHA Senior Investigator in Lee’s Summit, Missouri

GEHA is a leader in health services for federal employees and related customers, serving our chosen markets with low-cost offerings and best-in-class customer care, sustained by a nimble and efficient organization.

Under minimal supervision, the Senior Investigator investigates incidents of suspected fraud, waste and abuse that are sent to the GEHA Special Investigations Unit (SIU) from a variety of internal and external sources in accordance with OPM – OIG requirements. This role reports to the Investigations Supervisor.

SKILLS

Duties and Responsibilities:

  • Identify, investigate, analyze and evaluate instances of alleged fraud, waste and abuse related to the line of business assigned (pharmacy, medical, dental) in accordance with OPM – OIG carrier letter requirements.

  • Handle a variety of cases with increasing levels of complexity.

  • Conduct interviews, correspond with patients, providers, witnesses or other parties who may have information relevant to the investigation.

  • Utilize anti-fraud technology to identify new opportunities for investigation and development of cases.

  • Organize and prioritize investigations, securing needed information to substantiate or refute allegations through research and evidence gathering.

  • Prepare clear, concise and complete investigative reports and integrate medical review findings, if appropriate.

  • Support OPM – OIG communication requests as required, including providing claims data analysis, medical policy guidelines, EOB’s and other documents/information, as requested.

  • Understand, interpret, analyze and make investigative determinations concerning CPT, ICD and HCPCS coding as it relates to potential healthcare fraud schemes.

  • Maintain a basic understanding of statistical sampling methodologies and knowledge of relevant regulations, standards and emerging healthcare schemes.

  • Prepare OIG case notifications and make law enforcement referrals, as required.

  • Lead negotiations and settlement discussions with providers; create settlement agreements and coordinate recoupment activities, when appropriate.

  • Regularly interact and communicate with members, providers and employees during the investigative process.

  • Present findings to leadership, regulators and law enforcement; assists in legal proceedings as appropriate, including testifying in legal proceedings in support of investigations.

  • Develops and conducts training on healthcare fraud topics.

  • Travel as necessary to effectively investigate allegations of fraud.

  • Maintain confidentiality and discretion in all investigative activity.

  • Support other projects as assigned.

Required Qualifications:

  • Bachelor’s Degree

  • Minimum 5 years’ healthcare fraud, waste and abuse investigation experience within the assigned area (e.g, dental, pharmacy, medical)

  • Accredited Healthcare Fraud Investigator (AHFI) certification

Knowledge and Skills:

  • In depth understanding of investigative processes within a healthcare environment

  • Strong knowledge of federal and state guidelines as well as ICD, CPT, HCPCS, DRG, and revenue codes

  • Demonstrated ability to interpret and analyze healthcare data and records

  • Above average proficiency in the use of technology applications, particularly Excel, MS Access, Word, and others as necessary

  • Ability to quickly adapt to different anti-fraud technology solutions

  • Possess integrity, professionalism, excellent interpersonal skills; excellent communication skills, both written and oral

  • Demonstrated ability to work independently

  • Critical problem-solving skills and attention to details

OR Any combination of academic education, professional training or work experience, which demonstrates the ability to perform the duties of the position

Preferred: Accredited Healthcare Fraud Investigator (AHFI) certification, Certified Fraud Examiner (CFE) or Certified Professional Coder (CPC)

GEHA is an Equal Opportunity Employer. GEHA will not discriminate against employees or applicants because they have inquired about, discussed, or disclosed their compensation or the compensation of another employee or applicant. Our company's corporate headquarters is located in Lee's Summit near Douglas Rd and I-470 with a total of five locations in the Kansas City metropolitan area.

GEHA is a leader in health services for federal employees and related customers, serving our chosen markets with low-cost offerings and best-in-class customer care, sustained by a nimble and efficient organization.

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