JOB SUMMARY: Conduct in-depth investigations of suspected fraud involving the full range of products at AMERIGROUP.
PRIMARY RESPONSIBILITIES:
1. Conducts investigations into possible irregularities to detect, curtail fraud, and recover lost assets.
2. Strive to develop sufficient evidence to conclusively establish facts.
3. Conduct comprehensive interviews/interrogations with providers, subscribers and witnesses to obtain information which would be considered admissible under generally accepted criminal and civil rules of evidence.
4. Establish and maintain working relationships with all appropriate law enforcement and regulatory personnel, and additionally maintain rapport with industry peers.
5. Using Fraud detection software, PINS (Provider Indexing System) analyze data as part of the investigative process.
6. Prepare and submit findings and make recommendations to management.
7. Effectively communicates accurate information to superiors, team members and other appropriate staff in a timely, accurate and courteous manner.
8. Conduct special studies for management such as those required to determine compliance with new provider contracts, laws or regulations.
9. Assist in the conduct of fraud awareness training sessions.
10. Attend anti-fraud training seminars as required.
11. Other duties as requested or assigned.
EDUCATION AND EXPERIENCE:
· A Bachelor's degree or equivalent experience in Criminal Justice, Business, Insurance, Medical Insurance Claims, or other investigative field required.
· Minimum two years experience conducting full scale insurance investigations and interacting with state, federal and local law enforcement agencies.
OR
· A minimum of five years of law enforcement experience including demonstrated experience in
conducting full scale investigations
CERTIFICATION AND LICENSURE:
· Certified Fraud Examiner (CFE) Preferred
· Accredited Health Care Fraud Examiner (AHFI) Preferred
Knowledge and Skills:
· Solid knowledge of insurance law federal, state, civil and criminal statues.
· Working knowledge of Microsoft applications, especially Excel required.
· AMISYS or related claims processing system preferred.
· Clinical experience preferred.
· RN or LPN experience a plus.
· Excellent interpersonal skills, including the ability to work with all levels of personnel and the ability to work across all lines of the organization.
· Superior verbal and written communication skills.
· Ability to initiate and coordinate activities to meet goals and objectives.
· Ability to handle multiple priorities simultaneously with a high quality result.
· Appreciation of cultural diversity and sensitivity towards target population.
· Ability to work independently.
PHYSICAL REQUIREMENTS:
· Travel required (approximately 5%)
· Drive a automobile
· Must be able to operate a computer
· Must be able to operate a telephone
Equal Employment Opportunity
In accordance with state and federal laws, employment offers are tendered solely on the basis of qualifications without regard to race, religion, color, national origin, age, sex, marital status, sexual orientation, handicap (including disabled veterans) or Vietnam Era veteran status.
AMERIGROUP administers pre-employment drug testing as a condition of employment and a satisfactory criminal history background report.
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