Fraud Investigator - Medicaid

SafeGuard Services (SGS), a subsidiary of Peraton, performs data analysis, investigation, and medical review to detect, prevent, deter, reduce, and make referrals to recover fraud, waste, and abuse.

What you'll do:

The Fraud Investigator is responsible for researching and assessing leads of potential fraud, waste and/or abuse in the Medicare and Medicaid programs.  Job responsibilities include contacting the beneficiary, request and review of medical records pertaining to the services in question and making recommendations for appropriate action.  Appropriate actions may include calculation of overpayment or referral to investigations for further review.  

• An investigator is expected to perform a variety of investigations involving medical professional service providers and develop cases for future action, including referral to law enforcement, education, over payment recovery and other administrative actions.
• Perform research, analyze data, draw conclusions to determine if leads will be vetted for further investigation or closed.
• Under general supervision, examine the results of the investigation to ascertain if the allegations have been corroborated and work with others to determine the appropriate steps that need to be taken to address the issues.
• The investigator also may work as part of a team as there may be times when the investigator needs to work with state and/or federal investigators and other personnel.
• Present and document issues of concern, citing regulatory violations, alleging schemes or scams to defraud the Government.
• Organize a file, accurately and thoroughly document all steps.
• Use good judgment working under general supervision and direction.
• Handle multiple assignments concurrently; organize and analyze billing patterns; conduct interviews and obtain statement from beneficiaries/recipients and others.
• Attend meetings, training, and conferences.
• Some overnight travel required.
• Research and understand the relevant offenses being investigated; conduct efficient and effective analysis and research concerning those alleged offenses and detect or verify suspected violations; obtain information and evidence by observation, record examination, and interview.
• Prepare investigative reports that apply regulations or rules to the program(s) affected by the behavior being investigated. There may also be times when the investigator will need to apply federal or state laws.
• Prepare correspondence; that reflects attention to detail and meets quality standards.
• Employ effective oral communication; be objective and accurate and communicate with others with tact.
• Be flexible in planning activities and adopt effective courses of action.
• Work with health privacy information, and must maintain confidentiality and understand all the laws, rules and regulations concerning health privacy.

Telework position from Eastern Time Zone

Basic Qualifications:

• 5 years with BS/BA; 3 years with MS/MA; 0 years with PhD
• Knowledge of Medicare and/or Medicaid programs and the rules, regulations, policies, and procedures
• Strong interpersonal, analytical, research, and organizational skills are required.
• Ability to work in a fast-paced changing environment with limited supervision.
• Excellent organizational, scheduling and prioritization skills
• Excellent verbal and written communications
• Strong PC knowledge and skills
• Must reside in the Eastern time zone.
• U.S. Citizenship is required.

Desirable Qualifications:

• Strong background in investigations, 3 years preferred.
• Experience in reviewing claims for technical requirements, performing medical review, and/or developing fraud cases.
• Knowledge of investigative practices regarding healthcare providers.
• Background in evaluating, reviewing and analyzing medical claims and records.
• Ability to communicate effectively, internally and externally.
• Ability to handle confidential material.
• Ability to report/document work activity on a timely basis.
• Ability to interpret laws and regulations.
• Ability to work independently and as a member of a team to deliver high quality work.

Essential Functions:

• This position may require the incumbent to appear in court to testify about work findings.
• Ability to perform research and draw conclusions
• Ability to present issues of concern, citing regulatory violations, alleging schemes or scams to defraud the Government
• Ability to organize a case file, accurately and thoroughly document all steps taken
• Ability to compose correspondence, reports and referral summary letters
• Ability to educate providers, provider associations, law enforcement, other contractors and beneficiary advocacy groups on program safeguard matters
• Ability to communicate effectively, internally and externally
• Ability to interpret laws and regulations
• Ability to handle confidential material.
• Ability to report work activity on a timely basis.
• Ability to work independently and as a member of a team to deliver high quality work
• Ability to attend meetings, training, and conferences, overnight travel required.

Peraton is a next-generation national security company that drives missions of consequence spanning the globe and extending to the farthest reaches of the galaxy. As the world’s leading mission capability integrator and transformative enterprise IT provider, we deliver trusted, highly differentiated solutions and technologies to protect our nation and allies. Peraton operates at the critical nexus between traditional and nontraditional threats across all domains: land, sea, space, air, and cyberspace. The company serves as a valued partner to essential government agencies and supports every branch of the U.S. armed forces. Each day, our employees do the can’t be done by solving the most daunting challenges facing our customers. Visit peraton.com to learn how we’re keeping people around the world safe and secure.