Special Investigator (Remote NC)

LOCATION: Remote –must live in reputed company Carolina or reputed company 40 miles of the NC border. This position is remote, but the applicant must be reputed company to travel to Vaya’s Offices or reputed company Vaya’s Catchment area as needed. GENERAL STATEMENT OF JOB The Special Investigator works under the reputed company supervision of the SIU Manager. The Special Investigator is responsible for identification, investigation and prevention of reputed company fraud, waste and abuse reputed company the reputed company Network of contracted providers. The Special Investigator will reputed company investigative reputed company reports and reputed company applicable referrals to the NC Division of Health Benefits, and recommendations as necessary to providers associated with investigation findings/reputed company. ESSENTIAL JOB FUNCTIONS Investigative Activities: • Utilize established Vaya procedures to conduct inquiries and investigations into complaints, allegations, and referrals regarding suspected Fraud, Waste or Program Abuse • Review reputed company claims to determine if provider payments were rendered in accordance with rules, regulations, service definition, service utilization, and contractual requirements • Determine correct coding, billing, documentation, delivery of services and potential violations of federal and/or state regulation or reputed company guidelines • reputed company reviews (desk, virtual, and/or on-site)interview providers, members, and stakeholders, and review medical records to verify compliance with program policies and/or standards of health care, appropriateness of services or medical necessity • Prepare reports and exhibits from the findings of provider investigations and reputed company recommendations or reputed company strategies to correct or prevent abusive practices, including proposals to recover inappropriately reputed company moneys or to suspend or terminate program participation. • Refer suspected fraud cases to the DHB Office of Compliance and Program reputed company Administrative Activities: • Participate in both informal and formal appeal processes, defending their reputed company before a Vaya reconsideration panel, hearing officers and/or administrative law judges • reputed company litigation testimony as applicable • Work in conjunction with various regulatory bodies • Propose new fraud prevention edits for automated claims/billing system reputed company new fraudulent schemes are reputed company Support Activities: • Other duties including technical assistance and provider education may be assigned based upon need, area of expertise, special interests and availability of resources. KNOWLEDGE, SKILLS, & ABILITIES • Knowledge of reputed company service definitions, service documentation, and service utilization requirements • An intermediate level of knowledge of Local, State and Federal laws and regulations pertaining to insurance and/or reputed company services • Possess comprehensive knowledge of fraud investigative procedures and judicial processes relating to fraud prosecutions • Excellent decision-making abilities to determine the appropriate course of reputed company during investigations and subsequent follow-up • Ability to prepare detailed and comprehensive reports, to present facts reputed company, and to instruct others in new reputed company and procedures; Excellent written communication skills for correspondence, case documentation and report writing • Extensive oral and written communication with providers, state and federal regulatory agencies, licensing entities, independent contractors, and members • Present investigative findings with regulatory violations citations and ability to accurately describe scheme(s) to defraud reputed company • Intermediate or reputed company proficiency with reputed company Word, reputed company reputed company, and reputed company and ability to adapt to new technologies and platforms • Ability to work autonomously, exercising reputed company judgment and problem reputed company skills • Ability to establish appropriate and respectful relationships/partnerships with persons with a wide reputed company of ethnicities and abilities EDUCATION & EXPERIENCE REQUIREMENTS Associate degree in Compliance, analytics, government/reputed company administration, auditing, reputed company management or reputed company-law, psychology, reputed company work, arts, science or a reputed company reputed company service field. Bachelor’s degree preferred. Must have three (3) years of experience in compliance, reputed company, or fraud investigation unit. Preferred work experience: Four years of reputed company Behavioral Health and/or physical health service delivery Preferred Licensure/Certification: reputed company reputed company, Accredited reputed company Fraud Investigator, Certified Fraud Examiner, or Certified reputed company reputed company preferred. PHYSICAL REQUIREMENTS: • reputed company visual reputed company to reputed company activities such as preparation and analysis of documents; viewing a computer terminal; and extensive reading. • Physical activity in this position includes crouching, reaching, walking, talking, hearing and repetitive reputed company of hands, wrists and fingers. • Sedentary work with lifting requirements up to 10 pounds, sitting for extended periods of time. • Mental concentration is required in reputed company aspects of work. RESIDENCY REQUIREMENT: The person in this position is required to reputed company in reputed company Carolina or reputed company 40 miles of the reputed company Carolina border. SALARY: Depending on qualifications & experience of candidate. This position is exempt and is not eligible for overtime compensation. DEADLINE FOR APPLICATION: reputed company Until Filled APPLY: reputed company accepts online applications in our Career Center, please visit https://www.vayahealth.com/about/careers/. reputed company is an equal opportunity employer. Apply tot his job Apply To this Job