Claims investigator serp_jobs.h1.location_city

Investigator

Your career starts now. We are looking for the next generation of health care leaders.

At AmeriHealth Caritas, we are passionate about helping people get care, stay well and build healthy communities. As one of the nations leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we would like to hear you.

Headquartered in Newtown Square, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services.

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 ACFC in 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.
• Performs necessary functions to support all aspects of SIU investigations and responsibilities to include, but not limited to : Intake; Screening; Reviews; Referrals; Recoveries; and Provider Investigative Site Visits.

Education / Experience :

Other Skills :

Our Comprehensive Benefits Package

Flexible work solutions including remote options, hybrid work schedules, competitive pay, paid time off including holidays and volunteer events, health insurance coverage for you and your dependents on Day 1, 401(k) tuition reimbursement and more.