SIU Investigator

WellCare Health Plans, Inc. (NYSE:WCG) a Fortune 1000 company, is the nation?s leading provider of government health insurance products dedicated to government-sponsored health plans such as Medicare, Medicaid, State Children?s Health Insurance Programs, Medicare Prescription Drug Plans and others. Founded in 1985, our team of 2,500 associates and over 20,000 physician partners serve 1.4 million members across the U. S. Our company headquarters are based in Tampa, FL. For more information about WellCare, please visit the Company?s website at www.wellcare.com.

 

We are looking to add SIU Investigators to our team.If you truly believe in teamwork, consistently demonstrate a high level of integrity and want to be a part of a dynamic, growing organization, then this may be the opportunity for you.

 

Job Summary:

Position is responsible for performing in-depth evaluation of potential fraud cases and developing cases that may involve high dollar amounts, sensitive issues, or cases that otherwise meet criteria for referral to federal, state and/or local law enforcement.

 

Essential Functions:Conduct independent investigations resulting from the discovery of situations that potentially involve fraud or abuse Take phone calls and referrals from within and outside the company Investigate, recover and close high level, high exposure, complex cases Do on-line research on providers and procedures Design and run adhoc reports to identify or verify aberrant behavior in providers/members Develop criteria, run and interpret system reports based on allegations Review and analyze information in various reporting systems Prepare professional, clear letters to members and or providers to obtain information Communicate with internal and external parties in a professional manner Respond to subpoenas in a professional and timely way Development and maintain liaison relationships with Law Enforcement, DOI, OIG and FBI, Postal Inspectors and CMS Clearly document case activities in case tracking system Meet state requirements for timely fraud referrals and reporting Prepare evidence packages for referral to law enforcement or internal/external counsel Assist in the review of medical records and coding issues.  Prepare cases for physician review Represent the company in both civil and criminal litigation.  Responsible for the recovery of money lost by fraudulent acts perpetrated by members or providers Other duties as assigned

 

Requirements:Understand healthcare fraud and abuse and how it impacts the cost of healthcare Understand managed care and how healthcare works in real life Ability to write clear and concise business letters and communicate complex cases to all level audiences Excellent oral communication skills Understanding of CPT, ICD-9, HCPC, and DRG coding Systems savvy; ability to use claim reporting systems Able to identify cases without potential, close and move forward Critical thinker Ability to travel occasionally to interview providers or appear in court Very well organized, detail oriented Able to handle a fast-paced and demanding environment with rapidly changing priorities

 

Minimum Qualifications/Education:Bachelor?s degree in criminal justice or related field, OR a bachelor?s degree and four years of insurance claims investigation experience, OR five years of professional investigation experience with law enforcement agencies, OR a bachelor?s degree and seven years of professional investigation experience involving economic or insurance related matters, OR RN licensedRN licensed is preferredCoding certification is preferred

 

Computer Skills:Experience in MS Word, Excel, and Outlook Experience using Internet Working knowledge of MS Access, Sidewinder and Crystal reporting systems is a plus SAS experience is a plus