Amerihealth Caritas Health Plan



Responsibilities:The Investigator is responsible for conducting comprehensive investigations of reported, alleged or suspected fraud involving the full range of products at the AmeriHealth Caritas Family of Companies (ACFC).Major Accountabilities:* Ensures compliance with all requirements related to Special Investigation Units and fraud, waste and abuse investigations.* Conducts investigations of potential fraud, waste and/or abuse with a focus on thoroughness and attention to detail, quality, timeliness and cost control.* Conducts comprehensive interviews with providers, members and witnesses to obtain information which would be considered admissible under generally accepted criminal and civil rules of evidence.* Proactively performs research using the Internet, data analysis tools, etc., to analyze aberrant claims billing and practice patterns.* Analyzes data as part of the investigative process using available fraud detection software and corporate resources.* Represents ACFCin conducting settlement negotiations with providers, counsel and/or other associated parties.* Prepares and submits investigative reports covering all phases of the investigation.* Interprets and conveys highly technical information to others.* Establishes and maintains liaison with public officials, law enforcement and others to obtain assistance in conducting investigations.Education/Experience:* Associate's Degree or equivalent work experience.* Accredited Health Care Fraud Examiner (AHFI) preferred.* Certified Insurance Fraud Investigator (CIFI) preferred.* Fraud Claim Law Specialist (FCLS) preferred.* Certified Fraud Examiner (CFE) preferred.* Valid driver's license required.* Ability to work independently with minimal supervision, and manage a high volume of assignments.* Strong verbal and written communication skills.* High degree of integrity and confidentiality required handling information that is considered personal and confidential.* Analytical skills and ability to make deductions; logical and sequential thinker.* A minimum of 3 years experience conducting comprehensive insurance investigations; interacting with state, federal and local law enforcement agencies.* Law enforcement experience preferred* SIU and/or State Medicaid regulatory compliance work experience a plus* Knowledge andproficiency in claims adjudication standards & procedures preferred* Experience with Medicaid, Medicare, and/or pharmacy benefit reimbursement.Specific experience required driven by business needs.* Solid knowledge of Medicaid, Medicare, and pharmacy benefit laws and requirements; federal, state, civil and criminal statutes.* Experience with decision support tools used for data analysis* Advanced knowledge and experience working on various approaches to fraud, waste and abuse* Working knowledge of Microsoft applications, especially Excel required.* Knowledge of available resources (internal and external) to assist in investigations.

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