Are you interested in becoming part of a dynamic team that is looking to innovate and improve?  

Do you want to be part of a company that is committed to giving back to the community? 

Point32Health is currently seeking highly motivated individuals to join our organization as an Investigator within our Special Investigations Unit (“SIU”). The Investigator is an essential team member of the SIU, responsible for leading complex provider investigations related to fraud, waste and abuse, and developing action plans to address the investigative findings and prevent future loss. The Investigator works closely with other members of the SIU to set investigative priorities, develop effective investigative strategies and techniques, and recommend measures to address new and evolving schemes.  

WHAT YOU WILL BE DOING:

• Leading complex investigations, involving internal and external research, detailed data analyses, review of medical records, and interviews of members, providers, and other third parties. 

• Applying laws, regulations, plan policies and guidelines, contract provisions, coding rules, coverage rules, and industry standards to information gathered during the investigation. 

• Preparing reports of investigative findings and reporting investigative findings to providers.  

• Working with SIU management to educate providers, recover overpayments, take action to prevent future loss, and monitor provider activity post-investigation  

• Identifying root causes of fraud, waste and abuse and recommending internal and external corrective actions to address these root causes.   

• Recommending investigative priorities, strategies, and techniques. 

• Working with the analytics and intake team to develop and refine data mining to address new and evolving schemes.  

• Sharing expertise and promoting investigative best practices among SIU management and staff. Educating and collaborating with various business units to raise awareness of potential FWA concerns. 

• Performing out-of-the-box thinking, collaborate with others, and make a difference every day!  

• Other duties as assigned by the Director.  

WHAT YOU NEED: 

• Bachelor’s degree, preferably in a clinical or scientific field, business, computer science, or criminal justice.  

• 3+ years related experience in audits/investigations (preferred). 

• Certified Professional Coder (“CPC”); Certified Fraud Examiner (“CFE”); Accredited Health Care Fraud Investigator (“AHFI”) designation a plus. 

• Clinical license or certification (e.g., RN, LCSW, CPhT) a plus  

• Ability to produce clear, concise, and well-organized documents. 

• Resilient, collaborative, flexible, innovative. (Same for all job descriptions.) 

WHAT MAKES US STAND OUT (Same for all job descriptions.) 

• Work-Life-Flexibility  

• Paid volunteer time off (up to 3 days annually) 

• Open Time Off (include for exempt positions only) 

• Annual Mini-Grant of $500 donated to a non-profit organization of the employee’s choice 

• Educational Reimbursement 

Disclaimer: 

The above statements are intended to describe the general nature and level of work being performed by employees assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of employees assigned to this position. 

What we build together changes our customer's health for the better. We are looking for talented and innovative people to join our team. Come join us!

Please note: As of January 18, 2022, all employees — including remote employees — must be fully vaccinated. This position will require the successful candidate to show proof of full vaccination against COVID-19. Point32Health is an equal opportunity employer, and will consider reasonable accommodation to those individuals who are unable to be vaccinated consistent with federal, state, and local law.

About Point32Health

The combination of Tufts Health Plan and Harvard Pilgrim Health Care represents the coming together of two of New England’s most iconic nonprofit health care companies. Representing nearly 90 years of combined service to our members and the community, together we are building upon our diverse legacies and innovative collaboration by making it our purpose to guide and empower healthier lives for our members — no matter their age, health, race, identity, or income.

That’s why we’ve named our new corporate entity Point32Health. The Point32Health name is inspired by the 32 points on a compass. It speaks to the critical role we play in guiding and empowering the people we serve to achieve healthier lives.

Point32Health is our corporate name. Harvard Pilgrim Health Care, Tufts Health Plan and our other brands will continue to show up as they do today—trusted, high-quality health plans for people across the country.

As Point32Health, we strive to be a different kind of nonprofit health and well-being company, with a broad range of health plans, and innovative tools that make navigating health and well-being easier, guiding our members at every step of their health care journey to better health outcomes. We are committed to providing high-quality and affordable health care, improving the health and wellness of our members, and creating healthier communities across the country.

This job has been posted by TalentBoost on behalf of Point32Health. TalentBoost is committed to the fundamental principle of equal opportunity and equal treatment for every prospective and current employee. It is the policy of TalentBoost not to discriminate based on race, color, national or ethnic origin, ancestry, age, religion, creed, disability, sex and gender, sexual orientation, gender identity and/or expression, military or veteran status, or any other characteristic protected under applicable federal, state or local law.

Req ID: R3749