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Healthcare Fraud Investigator
Cahaba Safeguard Administrators LLC Benefit Integrity Investigations (BI) leads efforts to identify, investigate and reduce fraud and abuse to the Medicare Program. By working with Medical Review and Data Analysis partners, BI identifies potential aberrancies that require further review to determine if an actual loss to the Program has occurred. Once a loss has been identified, BI coordinates appropriate response.
The Healthcare Fraud Investigator is responsible for identifying, reviewing, analyzing and developing allegations of fraud and abuse against Medicare and/or Medicaid funds in accordance with the regulatory guidelines set forth by CMS. The position will proactively work a caseload for possible referral to external governmental agencies for further investigation/prosecution. This position is responsible for prioritizing the case workloads, researching Medicare and/or Medicaid medical review guidelines, and state and federal laws. The Healthcare Fraud Investigator must be able to remain objective and possess strong analytical skills to assess and evaluate medical treatment claims to determine if fraud and/or abuse is present. This position is also responsible for requesting and analyzing data and medical records for case development in a multi-state jurisdiction with multiple benefit structures (including Part A, Part B, DME and Home Health and Hospice) and multiple claims processing systems. In addition, the Healthcare Fraud Investigator will actively communicate with law enforcement, CMS, the medical community, beneficiaries, Medicare Fair Hearings and Administrative Law Judges on a regular basis.
Summary of Qualifications
1. Bachelor’s degree in Accounting, Health Administration, Business, Criminal Justice or related field
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