Special Investigator

Investigator Position

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

This position is remote however, you must be able to travel within Ohio as business needs.

At AmeriHealth Caritas, we are passionate about helping people get care, stay well and build healthy communities. As one of the nation's 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:

• Bachelor's degree with a minimum of two years of experience in the healthcare field working in fraud, waste, and abuse investigations and audits OR
• An associate's degree, with a minimum of four years of experience working in healthcare fraud, waste, and abuse investigations and audits.
• Experience and training/certifications commensurate with position requirements in lieu of formal educational requirements for the Lead SIU Investigator position may be considered.
• Valid driver's license required.
• Data Analytics experience preferred.
• 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 3-5 years experience conducting comprehensive health care fraud investigations; interacting with state, federal and local law enforcement agencies.

Other Skills:

• Health care industry and/or Medicare/Medicaid/Pharmacy/Behavioral Health/Pharmacy Benefit Management knowledge required.
• Clinical Experience preferred.
• SIU and/or State Medicaid regulatory compliance work experience preferred.
• Knowledge and proficiency in claims adjudication standards & procedures preferred.
• 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.

Diversity, Equity, and Inclusion

At AmeriHealth Caritas, everyone can feel valued, supported, and comfortable to be themselves. Our commitment to equity means that all associates have a fair opportunity to achieve their full potential. We put these principles into action every day by acting with integrity and respect. We stand together to speak out against injustice and to break down barriers to support a more inclusive and equitable workplace. Celebrating and embracing the diverse thoughts and perspectives that make up our workforce means our company is more vibrant, innovative, and better able to support the people and communities we serve. We keep our associates happy so they can focus on keeping our members healthy.

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.