Position: Fraud Investigator

Location: Baltimore OR Owings Mills MD (Remote/ Hybrid)

Job Type: 6 months Contract - Possible extension

Hiring Manager Notes:

• This team is tasked with identification, remediation and prevention of fraud, waste and abuse resulting in savings and recovery of funds.
• This project is focused on BG research in enrollment fraud. Needs someone to come onboard and look through enrollment files.
• Remote in EST time zone OR on-site around 2 times per week in Baltimore and/or Owings Mills.
• Must have analytical skills, can do research, great with documentation and comm, great with MS office.
• Will have to do research to make sure members are who they say they are, living where they say they live, etc.
• Will be doing preliminary research for the actual Investigators.
• Preferred: Healthcare bg, compliance bg, data analytic bg,
• Will be one round of interview. Video conference

Job Description:

Job Duties: The role of the Special Investigations Unit (SIU) Investigator is to assist in the reduction and recuperation of losses through the detection, investigation, and resolution of low to medium levels fraud, waste, and abuse schemes, resulting in the savings and recovery of funds

Responsibilities:

• Independently conduct low to medium level investigations and provide support as part of an assigned team to all levels (low to medium) investigations of suspected fraud, waste, and abuse. In conjunction with assigned team or management, develop and execute investigative plans that may include performance of audits of financial business records, provider and subscriber medical data, claims, systems reports, medical records, analysis of contract documents, provider/subscriber claims history, benefits, external data banks and other documents to determine the possible existence of fraud and/or abuse. Provide support for offsite audits/investigations and interviews when requested. Research provider/subscriber claims activity, operations manuals, data systems, medical policies, job duties and group benefit contracts to identify control deficiencies and non-compliance. Investigator will develop documentation to substantiate finding including formal reports, spreadsheets, graphs, audit logs, use of anti-fraud software and appropriately sourced reference materials. Must ensure audits and investigations are timely, effective and result in an overall achievement of unit goals.
• Investigator researches and analyzes claims data using company anti-fraud software, Excel, and other tools to proactively identify new potential cases. Investigator will develop documentation that supports conclusions, recommendations, and substantiates findings including formal correspondence, audit reports, spreadsheets, graphs, audit logs, anti-fraud software analysis, and appropriately sourced reference materials. Investigator ensures timely maintenance and organization of case file documentation with a high level of detail and accuracy that clearly and concisely outlines investigative steps, case synopses, and findings and to preserve as potentially discoverable material
• Initiate claim adjustments, voucher deducts, and voluntary refunds in order to recover funds. Record recoveries and savings following established processes.
• Perform special projects as assigned by management to meet the needs of the Special Investigations Unit.

Qualifications:

Education Level: Bachelor's Degree

Experience: 2 years insurance, investigative, health care, nursing or law enforcement. In lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the

required work experience.

Preferred Qualifications:

Credential in a health care or investigations related area such as Certified Fraud Examiner (CFE),

Accredited Health Fraud Investigator (AHFI), RN/LPN, or Certified Professional Coder (CPC).

Knowledge of ICD 10 and CPT Codes, medical terminology, extensive training in claims and subscriber customer service methods, and previous experience in the health care industry.

Knowledge, Skills and Abilities (KSAs):

Knowledge of laws that pertain to public and insurance funds - Proficient

Excellent communication skills both written and verbal. - Proficient

Ability to recognize, analyze, and solve a variety of problems. - Proficient

Ability to maintain effective interpersonal relationships - Proficient

Dexian is a leading provider of staffing, IT, and workforce solutions with over 12,000 employees and 70 locations worldwide. As one of the largest IT staffing companies and the 2nd largest minority-owned staffing company in the U.S., Dexian was formed in 2023 through the merger of DISYS and Signature Consultants. Combining the best elements of its core companies, Dexian's platform connects talent, technology, and organizations to produce game-changing results that help everyone achieve their ambitions and goals.

Dexian's brands include Dexian DISYS, Dexian Signature Consultants, Dexian Government Solutions, Dexian Talent Development and Dexian IT Solutions. Visit https://dexian.com/ to learn more.

Dexian is an Equal Opportunity Employer that recruits and hires qualified candidates without regard to race, religion, sex, sexual orientation, gender identity, age, national origin, ancestry, citizenship, disability, or veteran status.