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Description
Job Title:
Sr Investigator - Corporate Investigations
Job ID:
10637
Location: Virginia Beach, VA
Full/Part Time:
Full-Time
Regular/Temporary:
Regular
JOB SUMMARY: Conduct in-depth investigations of reported, alleged or suspected fraud involving the full range of products at AMERIGROUP. Ensure compliance with contractual requirements related to Special Investigative Units and fraud, abuse and waste investigations.
PRIMARY RESPONSIBILITIES:
1.Maintain full investigative case load by conducting investigations into reported, alleged or suspected fraud.
2.Independently decides the most effective and efficient method of investigation for each individual case.
3.Prepares and documents investigative plans detailing the investigative pan of action according to department guidelines
4.Develops sufficient evidence to conclusively establish facts.
5.Conduct comprehensive interviews/interrogations with providers, members and witnesses to obtain information which would be considered admissible under generally accepted criminal and civil rules of evidence.
6.Establish and maintain working relationships with all appropriate law enforcement and regulatory personnel, and additionally maintain rapport with industry peers.
7.Analyze data as part of the investigative process using available fraud detection software and corporate resources.
8.Prepare and submit findings and make recommendations to management.
9.Independently represents AMERIGROUP in conducting settlement negations with providers, counsel and/or other associated parties
10.Effectively communicates accurate information to superiors, team members and other appropriate staff in a timely, accurate and courteous manner.
11.Conduct special studies for management such as those required to determine compliance with new provider contracts, laws or regulations.
12.Assist in the development and presentation of fraud awareness training sessions.
13.Attend anti-fraud training seminars as required.
14.Provide consultation to Fraud Investigators where high level technical expertise is necessary.
15.Manage assigned cases and continuously update the department's Case Management System with pertinent case details.
16.Perform out-of-office field investigation as appropriate, at times requiring out of area, overnight travel.
17.Testifies in criminal and civil legal proceedings as required.
18.Adhere to company and department policies and procedures.
19.Other duties as requested or assigned.
JOB REQUIREMENTS:
EDUCATION AND EXPERIENCE:
A Bachelor's degree preferred.
Minimum 2 years experience conducting full scale insurance investigations and interacting with state, federal and local law enforcement agencies; or.
Minimum of 4 years experience in Criminal Justice, Business, Insurance, Medical Insurance Claims, or other investigative field required.
Law enforcement experience preferred.
Clinical experience a plus.
CERTIFICATION AND LICENSURE:
Accredited Health Care Fraud Examiner (AHFI) preferred.
Certified Fraud Examiner (CFE) Preferred
Valid driver's license required.
Knowledge and Skills:
Solid knowledge of insurance law federal, state, civil and criminal statues.
Working knowledge of Microsoft applications, especially Excel required.
AMISYS or related claims processing system preferred.
Excellent interpersonal skills, including the ability to work with all levels of personnel and the ability to work across all lines of the organization.
Understanding of HCFA 1500 and UB92 claim billing forms
Advanced understanding of common claim coding (CPT-4, ICSD, HCPCS)
Superior verbal and written communication skills
Intermediate MS Office skills
Analytical and keyboard skills
Ability to initiate and coordinate activities to meet goals and objectives
The highest levels of ethics, integrity and professionalism
Ability to handle multiple priorities simultaneously with a high quality result.
Appreciation of cultural diversity and sensitivity towards target population.
Ability to work independently
PHYSICAL REQUIREMENTS:
Travel required (approximately 25%)
Drive a automobile
Must be able to operate a computer
Must be able to operate a telephone
Equal Employment Opportunity
In accordance with state and federal laws, employment offers are tendered solely on the basis of qualifications without regard to race, religion, color, national origin, age, sex, marital status, sexual orientation, handicap (including disabled veterans) or Vietnam Era veteran status.
AMERIGROUP administers pre-employment drug testing as a condition of employment and a satisfactory criminal history background report.
Details:
Job Id:
629848A1
Posted / Updated:
11/21/2009 2:52:27 AM
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