ForHealth Consulting at UMass Chan Medical School · 5 hours ago
Fraud Investigator II
Westborough, MA
Full-time
Hybrid
Mid, Senior Level
5+ years expForHealth Consulting at UMass Chan Medical School is dedicated to creating a more equitable healthcare system. The Fraud Investigator II will analyze claims data and lead investigations to protect the integrity of the Massachusetts Medicaid program, ensuring taxpayer dollars are used appropriately.
Management Consulting
Responsibilities
Use your expert knowledge of Medicaid regulations, healthcare policies, and industry standards to perform independent data mining and analysis to identify outliers, trends, and suspicious billing activity
Build sophisticated algorithms, queries, and reports to detect fraud, waste, and abuse
Review large volumes of claims to ensure compliance with regulations, policies, and contract terms
Prepare clear, accurate investigative reports; calculate overpayments; and issue findings based on agency procedures
Communicate directly with providers regarding audit results, recoveries, and education opportunities
Recommend improvements to policies, systems, and analytical tools to enhance FWA detection
Mentor Investigator I staff and serve as a resource for complex or specialized algorithms
Keep leadership updated on case progress and propose new investigative initiatives
Manage all case documentation in the tracking system with accuracy and timeliness
Contribute to special projects and department-wide integrity initiatives as needed
Qualification
Required
A Bachelors degree in Business administration, finance, public health or related field; or equivalent years of experience
5-7 years of related experience in fraud examination, healthcare, business, finance or related field; with at least 2 years of experience conducting data mining in the healthcare insurance industry and claims related experience
Knowledge of coding, reimbursement and claims processing policies
Knowledge of the principles and practices of medical auditing
Strong analytical and qualitative skills as well as problem solving skills with the ability to look for root causes and implement workable solutions
Knowledge of the law and regulations as it relates to fraud and fraud investigations
Must have a track record of producing high quality work that demonstrates attention to detail
Ability to multi-task, establish priorities and work independently to achieve objectives
Ability to function effectively under pressure
Proficient in Microsoft Office applications (Word, Excel, PowerPoint and Access)
Excellent Customer service skills with the ability to interact professionally and effectively with providers, third party payers, and staff from all departments
Strong Interpersonal skills with the ability to work in a fast paced environment whether as a team member or an independent contributor
Strong oral and written communication skills including internal and external presentations
Preferred
Prefer individual possessing the following certification: CPC
Advanced Microsoft Excel software skills
Knowledge of State and federal regulations as they apply to public assistance programs
Strong Decision-making skills with the ability to investigate and weigh alternatives and select the appropriate course of action
Creative thinking skills with the ability to ask the needed “bigger- picture” questions that lead to process and team improvements
Benefits
Flexible hybrid schedule
Excellent state benefits
Company
ForHealth Consulting at UMass Chan Medical School
ForHealth Consulting partners with purposeful organizations, including state Medicaid agencies and health and human services organizations, to make the healthcare experience better for all – more equitable, effective, and accessible.
501-1000 employees
Funding
Current Stage
Late StageLeadership Team
Carly Gould
Senior Human Resources Business Partner
Jatin Dave
Chief Medical Officer, MassHealth
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