Centers Plan for Healthy Living

  • Junior Compliance Investigator

    Job Locations US-NY-Staten Island
    Posted Date 2 months ago(6/7/2018 10:59 AM)
    ID
    2018-1315
    # of Openings
    1
    Category
    Compliance
  • Overview

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    JOB SUMMARY:

     

    Under the direct supervision of the Director of Operational Compliance, and working closely with the Compliance Investigator/Auditor, the Junior Compliance Investigator is responsible for assisting in all aspects of fraud and abuse investigations.

     

    Responsibilities

    PRIMARY RESPONSIBILITIES:

     

    • Support Auditor/Investigator in performing investigations
    • Make outbound calls to providers in order to obtain documents and statements in regards to investigations
    • Document all aspects of the investigative process
    • Prepare investigation reports and referrals for submission to government agencies
    • Make recommendations to the Director of Operational Compliance and Chief Compliance Officer for improvement and correction where identified.
    • Research suspicious claims activities
    • Conduct investigations/audits of suspect claims
    • Conduct site visits as warranted
    • Participate in recovery of wrongful payment to providers
    • Coordinate and track Compliance Department initiated corrective actions where necessary
    • Assist with the drafting and/or updating of Centers Plan for Healthy Living (CPHL) Compliance related policies and procedures
    • Other duties and special projects may be assigned

    Qualifications

    QUALIFICATIONS:

     

    • Bachelor's Degree required 
    • Four or more years of experience in compliance-related matters in the health care industry
    • Comprehensive knowledge of fraud investigative procedures and judicial processes relating to fraud prosecutions.
    • Knowledge of Medicaid and Medicare regulations.
    • Proven ability to communicate complex subjects to all levels of associates, management and external contacts.
    • Excellent communication, negotiation and conflict resolution skills, as well as the capability of taking the lead in interviews.
    • Strong technical and business writing skills demonstrating the ability to write reports and business correspondence and to prepare case files.
    • In-depth knowledge of the healthcare industry; fraud, waste and abuse audit operations, and claims handling and payment operations.
    • Ability to interact with others in one-on-one situations to identify issues/problems and provide training/coaching to correct problem areas.
    • Experience creating and implementing a healthcare anti-fraud program.

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