Senior Investigator Jobs

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It’s an exciting time to join the WellSense Health Plan, a growing regional health insurance company with a 25-year history of providing health insurance that works for our members, no matter their circumstances.

The Senior Investigator is responsible for the identification, investigation and prevention of healthcare fraud, waste and abuse and is a key contributor to the Plan’s member and provider fraud, waste, and abuse (FWA) detection, investigation, remediation, and prevention efforts.

The Senior Investigator conducts data mining, utilizes preliminary recommendations provided by the SIU Data Analyst, and applicable guidelines and other sources of information to identify potentially fraudulent or abusive behavior. The Senior Investigator will also develop, conduct, resolve, document, and report on investigations of tips, allegations, or data mining output that suggests potentially fraudulent or abusive behavior. The Senior Investigator’s scope of work may range from independent evaluation of preliminary information to on-site audit to participation in Federal or State prosecution of a case. The Senior Investigator routinely handles cases that are sensitive, high profile or complex, and cases involving multi-disciplinary provider groups, or cases involving multiple perpetrators or intricate healthcare fraud schemes.

Our Investment In You

• Competitive salaries
• Full-time remote work
• Excellent benefits

Key Functions/Responsibilities

• Serves as a lead contact for third party vendor investigation activity as assigned, as well as leading FWA related vendor meetings
• Adjusts claims according to investigative findings; and processes claims in SIU pend queues
• Collaborates with SIU Manager and/or Data Analyst to identify audit sample, either random or based on another approved methodology
• Drafts Corrective Action Plans, where appropriate, and submits to SIU Manager for approval
• Meets with providers on prepay review regularly to ensure current and future compliance
• Reviews preliminary findings from data mining, and requests pertinent additional data from the applicable parties including, but not limited to, the Data Analyst, SIU, or Contracting, Claims, Pharmacy, Provider Relations, Business Integration, and/or Customer Care departments, and makes a final triage recommendation
• Conducts data mining as well as analyzes data received from the Data Analyst, to identify potential fraud, waste or abuse; and assists less experienced investigators with data mining
• Demonstrates high level of knowledge and expertise during interactions and acts confidently when providing testimony during civil and criminal proceedings
• Conducts more high level, complex investigations of suspected fraud, waste and abuse
• As requested, participates in internal and/or external FWA-related information sharing sessions, which may include receiving and providing secure data pursuant to contractual requirements
• Creates detailed investigation reports, including follow-up or remedial action recommendations, per department protocol and presents to department management
• Coordinates with Provider Audit, Claims, Business Integration, Contracting, Compliance and/or Provider Relations staff when remedial actions such as pre-payment review, payment suspension, overpayment recovery, etc. dictate, including drafting provider notification letters and configuration tickets for same
• Provides on the job training to new Investigators and provides guidance for less experienced or skilled Investigators
• Cooperates with federal, state, and local law enforcement agencies in the investigation and prosecution of healthcare fraud and abuse matters
• Applying laws, regulations, plan policies and guidelines, contract provisions, coding rules, coverage rules, and industry standards to information gathered during the investigation
• Creates FWA trainings for internal Health Plan staff as well as for vendors delegated to investigate FWA on behalf of the Plan
• Conducts investigations including comprehensive reviews of any and/or all portfolio documentation and State-approved, where required, on-site or desk medical record reviews and/or member or provider interviews
• Drafts preliminary and final investigation results for submission to provider or potential response to member
• Determines course of appropriate action based on line of business, severity of issue, and Plan exposure
• Drafts responses to subpoenas and other regulatory inquiries for manager approval
• Initiates case portfolio initially including findings from data mining; over the course of the investigation, expands portfolio to include such documentation as relevant Plan policies and procedures, member and/or provider publications (e.g., Evidence of Coverage or contracts), medical records and audit findings, interview records, etc.
• Ensures accuracy and quality of work product by adhering to department’s data validation guidelines
• Maintain accurate, current and thorough updates in the department’s FWA databases at prescribed intervals and per department standards
• Prepares summary and/or detailed reports on investigation findings for referral to Federal and state agencies which may include but are not limited to state Medicaid agencies, Medicaid Fraud Control Units, the Attorney General’s Office, the Department of Insurance, and local law enforcement
• Drafts regulatory reports for manager approval

Qualifications

Education:

• Bachelor’s degree in Health Information Management, Health Care Administration, Nursing or Other Clinical Field, Public Health, Criminal Justice, Law Enforcement or other related field; an equivalent combination of education, training, and experience may be considered

Preferred/Desirable

• Advanced degree in an above noted area

Experience

• Minimum of five years of experience in a health care payer setting
• Minimum of five years of experience in a health care fraud control setting

Preferred/Desirable

• Four years of experience in a Medicaid or Medicaid Managed Care fraud detection unit (e.g., Special Investigations/Program Integrity Unit, Recovery Audit Contractor, Medicaid Fraud Control Unit) highly preferred
• Two or more years’ experience with Facets claim processing
• Five years of experience in the Managed Care industry preferred; four years’ experience in Medicaid Managed Care highly preferred

Certification/Conditions Of Employment

• National Health Care Anti-Fraud Association certification (AHFI), Certified Fraud Examiner (CFE), or America’s Health Insurance Plans Health Care Anti-Fraud Associate (HCAFA) designation

Preferred/Desirable

• Health care coding certification (CPC or CCS) highly preferred, and required within 12 months of employment

Competencies, Skills, And Attributes

• Time management skills necessary to meet established deadlines in a fast-paced environment, including the ability to re-prioritize tasks as workload and time constraints dictate
• Strong verbal and written communication skills with the ability to clearly articulate thoughts, ideas, processes and requirements to both internal and external audiences and in potentially contentious situations
• Proven ability to maintain objectivity and the utmost confidentiality
• Strong problem solving skills, including with the ability to determine root causes and to define workable solutions
• Intermediate level skills in developing investigative strategies
• Organization and analytical skills necessary to aggregate potentially disparate information from multiple sources
• Demonstrated intermediate proficiency with Microsoft Office products, including but not limited to Word, and Excel, including Excel pivot tables
• Customer service skills with the ability to interact professionally and effectively with a wide variety of providers, third party payers, staff from all departments within and outside the Plan, law enforcement, and regulatory partners
• Creative thinking skills that allow one to ask the bigger-picture questions that lead to future improvements/gains
• Ability to weigh alternatives and select the most appropriate course of action, given the individual circumstances of a case
• Attention to detail with excellent proof reading and editing skills

Working Conditions And Physical Effort

• Limited travel is required

About WellSense

WellSense Health Plan is a nonprofit health insurance company serving more than 740,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded in 1997, WellSense provides high-quality health plans and services that work for our members, no matter their circumstances.

• WellSense will require proof of COVID-19 vaccination(s) as a term of employment for all employees. The company may make exceptions to this requirement in certain limited circumstances for religious or medical purposes.

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