Lead Fraud Investigator

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Job Summary

Job Description Summary
This position is responsible for planning and developing investigation tools and techniques to conduct detailed investigations of potentially fraudulent claim activity by members, employees and providers, both internally and externally initiated, and makes recommendations for prosecution, recovery, and litigation. Also, review operational controls, claim system controls and protocols, and recommends enhancements to reduce the potential for fraud.

JOB REQUIREMENTS:

• Bachelor’s Degree
• 7 years’ law enforcement experience (local, state, or federal) or 7 years fraud investigative experience. Experience directing complex fraud investigations which result in criminal or civil prosecutions.
• Experience planning and conducting interviews which develop significant information in furtherance of complex fraud, waste, and abuse investigations.
• Familiarity with state and federal laws applicable to health care fraud.
• Ability to develop effective liaison relations which facilitate case identification, investigation, and prosecution.
• Ability to independently prepare reports of interview and other documentation accurately reflecting investigative activity and results.
• Clear and concise verbal and written communication skills.
• Self-motivated, results oriented with demonstrated leadership skills.

PREFERRED REQUIREMENTS:

• Accredited Health Care Fraud Investigator
• Certified Professional Coder
• Certified Fraud Examiner
• Medicare Advantage Experience

This is a Flex (Hybrid) role: 3 days in office; 2 days remote.

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Pay Transparency Statement:

At Health Care Service Corporation, you will be part of an organization committed to offering meaningful benefits to our employees to support their life outside of work. From health and wellness benefits, 401(k) savings plan, pension plan, paid time off, paid parental leave, disability insurance, supplemental life insurance, employee assistance program, paid holidays, tuition reimbursement, plus other incentives, we offer a robust total rewards package for employees.  Learn more about our benefit offerings by visiting https://careers.hcsc.com/totalrewards.

The compensation offered will vary depending on your job-related skills, education, knowledge, and experience. This role aligns with an annual incentive bonus plan subject to the terms and the conditions of the plan.

Flex employees are expected to be in the office a minimum of three days a week. Management will have discretion to modify an employee's weekly schedule for exigent circumstances.

HCSC Employment Statement:

We are an Equal Opportunity Employment employer dedicated to providing a welcoming environment where the unique differences of our employees are respected and valued. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, protected veteran status, or any other legally protected characteristics. We are a drug-free and smoke-free workplace. Employment may be contingent upon successful completion of drug screening in accordance with applicable law.

Base Pay Range

$69,800.00 - $125,900.00

Exact compensation may vary based on skills, experience, and location.