• Job Description

  Req#: 5000977946306

  Why This Role is Important to Us

  The Associate Investigator works with a growing team conducting and managing Health Care Fraud, Waste and Abuse investigation and prevention activities under the general direction of the Director or designee.

  Supervision Exercised: No

  What You'll Be Doing

  • Plan, organize, and execute investigations or audits utilizing document review, witness interviews and data analysis to identify, evaluate and measure potential healthcare fraud and abuse to determine valid cases for appropriate action.
  • Document and track activity in internal database, provide case updates on progress of investigation, and coordinate with management recommendations and further actions and/or resolutions.
  • Prepare detailed reports on investigative findings for internal tracking, review and referral to Federal and State agencies as indicated.
  • Utilize data mining and visualization programs to design queries and analyze claims data to detect outliers or suspicious patterns for further investigation.
  • Conduct detailed research to identify and apply appropriate regulatory, contractual and industry requirements to the different benefits and products within investigations.
  • Proactively seek out and develop leads, resources and opportunities from a variety of sources, and develop and maintain relationships with enterprise, industry, law enforcement and other contacts.
  • Complete special projects and audits as required.
  • Understand and adhere to HIPAA privacy requirements.

  Working Conditions: Standard Office Conditions.

  What We're Looking For

  Education Required:

  • Bachelor's Degree or equivalent experience

  Experience Required:

  • At least three (3) years of related investigative, claims, compliance or analyst experience in healthcare, data reporting and/or data analysis required. Internships will be considered.
  • AHFI, CFE, CPC/medical coding, clinical background or formal data analyst background preferred.
  • Prior experience in health care compliance, regulation, SIU, government agency or similar position related to data analysis or an insurance-related field beneficial.
  • Proficiency in Microsoft Office (Word, Excel, PowerPoint, and Access) required.

  Knowledge, Skills & Abilities Required:

  • Demonstrated understanding of common fraud schemes and ability to review and evaluate assigned referrals and apply appropriate investigative strategies needed.
  • Strong knowledge of standard industry coding guidelines such as CPT, HCPCS, ICD 10 and NCCI.
  • Ability to independently develop and present verbal and written investigative and management reports.
  • Knowledge of federal and state laws and regulations pertaining to fraud, waste and abuse.
  • Desire to work in a collaborative and fast-paced team environment.
  • Strong interpersonal, oral and written communication skills including presenting to internal and external stakeholders.
  • Ability to think creatively and approach this work to achieve corrective actions and process improvements.

  Language(s) Required:

  • English

  Other Required:

  • Standard office equipment

  Actual Work Location

  Remote, Boston, Massachusetts 02108

  All Locations

  Remote - Boston

  Exempt / Not Exempt

  Exempt

• About the company

  Based in Massachusetts, Commonwealth Care Alliance (CCA) is a not-for-profit, community-based healthcare organization dedicated to improving care for individuals who are dually eligible for MassHealth (Medicaid) and Medicare with complex medical, behavioral health and social needs, including persons with disabilities. CCA offers two health plans: Senior Care Options (HMO SNP), for individuals ages 65 and over who have Medicare and MassHealth Standard or only MassHealth Standard; and One Care, a Massachusetts demonstration program for dual eligible individuals ages 21 to 64. These comprehensive health plans provide all the services covered under Medicare and MassHealth, and other benefits as determined necessary by an inter-professional care team in conjunction with CCA’s preferred provider network. For four consecutive years, CCA’s One Care plan received a top consumer rating for quality and access in the Consumer Assessment of Healthcare Providers and Systems (CAHPS) national survey of Medicare-Medicaid Plans (2016, 2017, 2018, and 2019), administered by the Centers for Medicare & Medicaid (CMS).

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