Investigator Senior - Fraud, Waste & Abuse (FWA)
- Employer
- UCare
- Location
- Minneapolis, Minnesota
- Posted
- Mar 03, 2023
- Closes
- Mar 22, 2023
- Ref
- 3420
- Category
- Healthcare
- Employment Status
- Full Time
Health Care that Starts with You!
Join a truly mission-driven organization! Independent, nonprofit UCare is recognized as one of the Minnesota's leading health plans. We provide more than 600,000 members across Minnesota and western Wisconsin with the health coverage plans and services they need to maintain and improve their health. The innovative coverage we create makes a difference for Medicare-eligible individuals, individuals and families enrolled in Minnesota Health Care Programs, such as MinnesotaCare and Medical Assistance, and disabled adults with special health care needs.
UCare is growing in size, membership, products, geographic coverage, and employees. We're an organization that's going places. Be part of a team that cares about you, be part of UCare.
Rewards
Enter a highly collaborative environment where people are truly engaged, and feedback is valued. You'll enjoy a competitive salary and benefits, as well as a host of other perks, including a nationally recognized wellness program, and a bright, open, award-winning office space in Northeast Minneapolis just minutes from major freeways and retail centers.
At UCare, we welcome and employ a diverse employee group committed to meeting the needs of UCare, our members, and the communities we serve.
www.ucare.org/careers/
EOE/AA
ABOUT UCARE
UCare offers Medicare, Medicaid, Individual and Family health plans - powered by the hardest working people in the industry. Our people powered teams de-complicate, advocate and always go the extra mile to help our members. We serve with integrity, compassion and commitment to do right by members, providers and government partners. Above all, we come to work excited to provide members a path for the best health of their lives.
WORKING AT UCARE
Working at UCare is more than a career; it's a mission. A mission that defines us as professionals, unites us as an organization and shapes how we interact with our members and each other. Employees join UCare and stay because of the opportunity to have a purpose-driven job.
Our strong culture has established UCare as a Star Tribune Top 200 Workplace for 13 consecutive years since the awards program began. It's a culture that embraces innovative ideas, strategic partnerships, and exemplary customer and provider experiences. Working at UCare is being a part of a people powered team dedicated to making a real difference in the lives of our members and communities.
INVESTIGATOR SENIOR - FRAUD, WASTE & ABUSE (FWA)
Work Location: Work from Home, In the Office or Office for Your Day
Position Description
As the Investigator Senior, you will be responsible to detect, prevent, investigate, and correct alleged or suspected fraud, waste and abuse (FWA) by providers or members. Conduct data mining, analysis and auditing/monitoring activities. Suggest integrity measures or program controls and engage in FWA prevention efforts. Prepare investigative reports for internal recovery efforts, corrective action(s), and/or referral to state and federal enforcement agencies. Represent UCare as a witness in court actions as required. Prepare data reports for submission to regulators. Act as back-up to SIU leadership, as needed.
• Collaborate with SIU leadership to investigate allegations of fraud, waste and abuse.
• Collect, review and analyze case evidence such as patient records, business records, financial ledgers, and claims data spreadsheets. Perform analysis of applicable regulations, contracts and policy manuals to determine whether violations exist.
• Write investigative reports summarizing evidence, investigative activities, and findings. This includes compiling and organizing accurate case file documentation and calculation of overpayments. Make referral of findings to law enforcement or regulators as appropriate and as directed by SIU leadership.
• Conduct interviews of witnesses or targets, and perform field work including provider site visits and surveillance, as needed.
• Manage large and/or complex investigations, providing guidance to investigative and operational team members.
• Mentoring less senior SIU staff in investigative and interview techniques, case development, and report writing.
• Represent UCare as a witness in court actions as required, under the direction of the SIU leadership.
• Support internal compliance reviews as appropriate, including accurate tracking of case information and timely reporting as needed for external audits and regulatory oversight. Act as back-up to SIU leadership, as needed.
• Serve as a resource for departments to research and resolve integrity inquiries and assist in identification of improvements to internal practices that may reduce or prevent FWA.
• Conduct data mining and data analysis using available tools and internal data warehouse. This includes intermediate to advanced functionality in Excel, performing manipulation, sorting, analysis, application and development of formulas, summarization and presentation of data in an understandable and reliable format. Develop query logic or algorithms for identification of aberrancies.
• Consult with legal, law enforcement and regulators regarding and respond to Requests for Information, as assigned.
• Other projects and duties as assigned.
Education
Bachelor's degree; demonstrated experience may be considered in lieu of degree.
Required Experience
Five years' experience performing full health care fraud investigations (lead to closure), or five years of experience performing other types of investigations with a minimum of three years of this performing full health care fraud investigations. Working knowledge of medical and pharmaceutical terminology. Demonstrated competence using data to perform investigations, including intermediate to advance Excel skills. Experience performing complex investigation oversight. Basic understanding of state and federal laws and regulations pertaining to health care. Experience writing complex reports.
Preferred Experience
Experience working in an SIU or performing healthcare fraud investigations. Knowledge of Medicare and/or Medicaid. Project management experience. Experience as a witness in court action or proceedings. Understanding of provider network or contract management.
THE UCARE DIFFERENCE
The UCare difference is our people power - employees actively working on the behalf of our members to get them access to the health care they need. We value and respect each individual's ideas and contributions, and provide the freedom to grow both personally and professionally. We are centrally located, and offer onsite education, equipment and wellness resources, and a myriad of volunteer activities. If you're looking for an inclusive environment that celebrates your people power, helps you build on your strengths and gives you the opportunity to truly make a difference, we invite you to apply.
As an Equal Opportunity/Affirmative Action Employer, we welcome and employ a diverse employee group committed to meeting the needs of UCare, our members, and the communities we serve.
JOB POST DATE: 3/2/2023
Join a truly mission-driven organization! Independent, nonprofit UCare is recognized as one of the Minnesota's leading health plans. We provide more than 600,000 members across Minnesota and western Wisconsin with the health coverage plans and services they need to maintain and improve their health. The innovative coverage we create makes a difference for Medicare-eligible individuals, individuals and families enrolled in Minnesota Health Care Programs, such as MinnesotaCare and Medical Assistance, and disabled adults with special health care needs.
UCare is growing in size, membership, products, geographic coverage, and employees. We're an organization that's going places. Be part of a team that cares about you, be part of UCare.
Rewards
Enter a highly collaborative environment where people are truly engaged, and feedback is valued. You'll enjoy a competitive salary and benefits, as well as a host of other perks, including a nationally recognized wellness program, and a bright, open, award-winning office space in Northeast Minneapolis just minutes from major freeways and retail centers.
At UCare, we welcome and employ a diverse employee group committed to meeting the needs of UCare, our members, and the communities we serve.
www.ucare.org/careers/
EOE/AA
ABOUT UCARE
UCare offers Medicare, Medicaid, Individual and Family health plans - powered by the hardest working people in the industry. Our people powered teams de-complicate, advocate and always go the extra mile to help our members. We serve with integrity, compassion and commitment to do right by members, providers and government partners. Above all, we come to work excited to provide members a path for the best health of their lives.
WORKING AT UCARE
Working at UCare is more than a career; it's a mission. A mission that defines us as professionals, unites us as an organization and shapes how we interact with our members and each other. Employees join UCare and stay because of the opportunity to have a purpose-driven job.
Our strong culture has established UCare as a Star Tribune Top 200 Workplace for 13 consecutive years since the awards program began. It's a culture that embraces innovative ideas, strategic partnerships, and exemplary customer and provider experiences. Working at UCare is being a part of a people powered team dedicated to making a real difference in the lives of our members and communities.
INVESTIGATOR SENIOR - FRAUD, WASTE & ABUSE (FWA)
Work Location: Work from Home, In the Office or Office for Your Day
Position Description
As the Investigator Senior, you will be responsible to detect, prevent, investigate, and correct alleged or suspected fraud, waste and abuse (FWA) by providers or members. Conduct data mining, analysis and auditing/monitoring activities. Suggest integrity measures or program controls and engage in FWA prevention efforts. Prepare investigative reports for internal recovery efforts, corrective action(s), and/or referral to state and federal enforcement agencies. Represent UCare as a witness in court actions as required. Prepare data reports for submission to regulators. Act as back-up to SIU leadership, as needed.
• Collaborate with SIU leadership to investigate allegations of fraud, waste and abuse.
• Collect, review and analyze case evidence such as patient records, business records, financial ledgers, and claims data spreadsheets. Perform analysis of applicable regulations, contracts and policy manuals to determine whether violations exist.
• Write investigative reports summarizing evidence, investigative activities, and findings. This includes compiling and organizing accurate case file documentation and calculation of overpayments. Make referral of findings to law enforcement or regulators as appropriate and as directed by SIU leadership.
• Conduct interviews of witnesses or targets, and perform field work including provider site visits and surveillance, as needed.
• Manage large and/or complex investigations, providing guidance to investigative and operational team members.
• Mentoring less senior SIU staff in investigative and interview techniques, case development, and report writing.
• Represent UCare as a witness in court actions as required, under the direction of the SIU leadership.
• Support internal compliance reviews as appropriate, including accurate tracking of case information and timely reporting as needed for external audits and regulatory oversight. Act as back-up to SIU leadership, as needed.
• Serve as a resource for departments to research and resolve integrity inquiries and assist in identification of improvements to internal practices that may reduce or prevent FWA.
• Conduct data mining and data analysis using available tools and internal data warehouse. This includes intermediate to advanced functionality in Excel, performing manipulation, sorting, analysis, application and development of formulas, summarization and presentation of data in an understandable and reliable format. Develop query logic or algorithms for identification of aberrancies.
• Consult with legal, law enforcement and regulators regarding and respond to Requests for Information, as assigned.
• Other projects and duties as assigned.
Education
Bachelor's degree; demonstrated experience may be considered in lieu of degree.
Required Experience
Five years' experience performing full health care fraud investigations (lead to closure), or five years of experience performing other types of investigations with a minimum of three years of this performing full health care fraud investigations. Working knowledge of medical and pharmaceutical terminology. Demonstrated competence using data to perform investigations, including intermediate to advance Excel skills. Experience performing complex investigation oversight. Basic understanding of state and federal laws and regulations pertaining to health care. Experience writing complex reports.
Preferred Experience
Experience working in an SIU or performing healthcare fraud investigations. Knowledge of Medicare and/or Medicaid. Project management experience. Experience as a witness in court action or proceedings. Understanding of provider network or contract management.
THE UCARE DIFFERENCE
The UCare difference is our people power - employees actively working on the behalf of our members to get them access to the health care they need. We value and respect each individual's ideas and contributions, and provide the freedom to grow both personally and professionally. We are centrally located, and offer onsite education, equipment and wellness resources, and a myriad of volunteer activities. If you're looking for an inclusive environment that celebrates your people power, helps you build on your strengths and gives you the opportunity to truly make a difference, we invite you to apply.
As an Equal Opportunity/Affirmative Action Employer, we welcome and employ a diverse employee group committed to meeting the needs of UCare, our members, and the communities we serve.
JOB POST DATE: 3/2/2023
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