Website CES, LLC
Integrity At Work
Job Description Summary:
Performs in-depth evaluation and analysis of potential healthcare fraud cases and requests for information using claims information and other sources of data. Supports the machine learning to identify complex cases that involve high dollar amounts, sensitive issues, or that otherwise meet criteria for referral to law enforcement, recoupment of overpayment, and/or administrative action based on reactive and proactive data analysis.
Work with the assigned supervisory attorneys, determine applicable administrative statutory and regulatory law, and identify possible health care fraud violations or causes of action.
Develop an understanding of all applicable federal, state or local laws to the extent necessary to make sound decisions on direction and scope of health care fraud investigations.
Determine proof required to assist in affixing legal responsibility for litigation, and devise methods for obtaining, preserving, and presenting evidence to the greatest effect.
Decide upon most efficacious methods for planning, scheduling, and conducting health care fraud investigations, and identify any resources that may be required.
Initiate contacts with federal, state and local officials, and other organizations and individuals related to the subject of investigation, for the purpose of gathering facts, obtaining statements, learning sequences of events, obtaining explanations and otherwise advancing investigative objectives.
Examine books, ledgers and payrolls, cost reports, billing statements, invoices, correspondence, computer data and other records pertaining to the transactions, events, or allegations under investigation.
Arrange for secure storage, preservation, organization and indexing of voluminous documentary evidence while maintaining the confidentiality of individually identifiable medical information.
Assist law enforcement agents in conducting interviews of witnesses
Prepare interim and final reports on progress of investigations for use by supervisory attorneys
Uses electronic databases to identify assets, documents, and other physical evidence.
Perform other related duties as assigned
Master’s degree in any Statistical or Mathematical fields, or a closely related field such as Engineering, Computer Science/Engineering/Applications, Management Information Systems, Industrial Engineering/Management or foreign degree equivalent is required
Prior healthcare experience, preferably in FWA detection
Knowledge of statistical analysis, algorithm development
Knowledge of SQL, R or Python to perform various types of data analysis
Preferred experience in the Healthcare Field
This is a full-time contract position with benefits.
Work shall be performed remotely, telework is permitted from a home office. Personnel working from home are required to supply the following: Cross-cut shredder, locking file cabinet, phone line for business use.
Travel may be required as necessary and will need prior management approval. All necessary travel expenses are reimbursable via GSA standards.
Equal Opportunity Employer/Veterans/Disabled.
For more information about CES, please visit www.cesnb.com.