Location:

Work from home (Pennsylvania)

Shift:

Days (United States of America)

Scheduled Weekly Hours:

40

Worker Type:

Regular

Exemption Status:

Yes

Job Summary:

Responsible for investigation and research initiatives related to prevention and detection of Fraud, Waste and Abuse in all the Health Plan lines of business. Assists in planning, organizing, and executing investigations or audits that identify, evaluate and measure potential healthcare fraud and abuse. Serves as a departmental liaison for fraud, waste and abuse while addressing areas of concern for internal and external customers. Adheres to policies, procedures, and regulations to ensure compliance and member safety.

Job Duties:

• Conducts investigations of potential fraud, waste and abuse.
• Interviews members, providers, provider staff and other witnesses and experts. Proactively performs research using the internet, data analysis tools, and interviews to improve investigation development.
• Performs data mining and analysis to detect aberrancies and outliers in claims data. Provides case updates on progress of investigations to internal departments, committees and management.
• Establishes and maintains quality relationships with public officials, law enforcement and others to obtain assistance in conducting investigations.
• Provides proactive case development support to develop quality leads and cases received from a variety of sources including CMS, OIG, fraud alerts, and referrals from internal and external stakeholders.
• Utilizes knowledge of coding, the Health Plan benefits, provider contracts, Pennsylvania state regulations relevant to the Health Plan, and claims adjudication.
• Reports to Management potential issues identified that relate to the Health Plan Fraud and Abuse policy Prepares concise investigatory reports to support findings of potential fraud, waste and abuse.
• Documents all investigative work in tracking software. Conducts onsite provider audits and investigations, provide member and provider and employee education related to fraud, waste, and abuse.
• Supports legal proceedings as needed, including law enforcement subpoenas, data requests, preparation for civil or criminal actions

Work is typically performed in an office environment. Travel may be required. Accountable for satisfying all job specific obligations and complying with all organization policies and procedures. The specific statements in this profile are not intended to be all-inclusive. They represent typical elements considered necessary to successfully perform the job.

This posting reflects an opening for Investigator Fraud Waste and Abuse and we are seeking candidates for that position. Geisinger reserves the right to consider applicants for higher levels of this role to include Investigator II Fraud Waste and Abuse based on their skills, qualifications, and experience. We encourage all qualified individuals to apply.

#LI-REMOTE

Position Details:

*Relevant experience may be a combination of related work experience and degree obtained (Associate’s Degree = 2 years; Bachelor’s Degree = 4 years).

Education:

High School Diploma or Equivalent (GED)- (Required)

Experience:

Minimum of 7 years-Relevant experience* (Required)

Certification(s) and License(s):

Skills:

Computer Literacy, Critical Thinking, Group Problem Solving, Health Insurance, Interpersonal Communication, Waterfall Model

OUR PURPOSE & VALUES: Everything we do is about caring for our patients, our members, our students, our Geisinger family and our communities.

• KINDNESS: We strive to treat everyone as we would hope to be treated ourselves.
• EXCELLENCE: We treasure colleagues who humbly strive for excellence.
• LEARNING: We share our knowledge with the best and brightest to better prepare the caregivers for tomorrow.
• INNOVATION : We constantly seek new and better ways to care for our patients, our members, our community, and the nation.
• SAFETY: We provide a safe environment for our patients and members and the Geisinger family.

We offer healthcare benefits for full time and part time positions from day one, including vision, dental and domestic partners. Perhaps just as important, we encourage an atmosphere of collaboration, cooperation and collegiality.

We know that a diverse workforce with unique experiences and backgrounds makes our team stronger. Our patients, members and community come from a wide variety of backgrounds, and it takes a diverse workforce to make better health easier for all. We are proud to be an affirmative action, equal opportunity employer and all qualified applicants will receive consideration for employment regardless to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or status as a protected veteran.