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)

Skills

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

About Geisinger

Founded more than 100 years ago by Abigail Geisinger, the system now includes ten hospital campuses, a 550,000-member health plan, two research centers and the Geisinger Commonwealth School of Medicine. With nearly 24,000 employees and more than 1,700 employed physicians, Geisinger boosts its hometown economies in Pennsylvania by billions of dollars annually. Learn more at geisinger.org or connect with us on Facebook, Instagram, LinkedIn and Twitter.

Equal Opportunity Employer

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, pregnancy, genetic information, disability, status as a protected veteran, or any other protected category under applicable federal, state, and local laws.

Our Vision & Values

Everything we do is about making better health easier 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.

Our Benefits

We offer healthcare benefits for full time and part time positions from day one, including vision, dental and prescription coverage.