Senior FWA Investigator

Our Promise
Through skill-building, leadership development and philanthropic opportunities, we provide opportunities to build communities and grow your career, surrounded by diverse colleagues with high ethical standards.

The Senior FWA Investigator will be part of the FWA team responsible for tracking and trending provider patterns through development of dashboards and claims data analyses to target provider outliers. The senior investigator is responsible for conducting investigations as needed, which will include medical record reviews, as well as obtaining any other documentation relevant to an investigation, documenting findings, and reporting to appropriate health plan. In addition, the senior investigator position will be responsible for maintenance and monitoring of provider disciplinary actions within the FWA department as a result of investigations. The Senior FWA Investigator will assist in training new investigators as well as monitor client FWA activities for compliance.

Functional Competencies

• Investigate dental cases of fraud, waste, and abuse timely and accurately of dental and vision network providers
• Develop and deploy effective and efficient investigative tools and best practice strategies for investigative processes within the FWA department
• Maintain accurate, current and thorough case information in the FWA tracking system
• Collect and secure documentation in relation to all FWA investigations; prepare summaries of findings as well as summary reports of outcomes
• Prepare investigative/client presentations for FWAent to both internal and external parties
• Identify and refer instances of suspected dental or vision fraud as appropriate to the Health Plan
• Accurately track overpayment recoveries, document and work with collection agency to collect when necessary
• Collect, collate, analyze, and interpret data relating to fraud, waste, and abuse referrals
• Collect, collate, analyze, and interpret data relating to internal investigative activities
• Identify payment integrity/cost avoidance opportunities resulting from investigations
• Assist in development of standard operating procedures as needed within the FWA department
• Ensure compliance of applicable federal/state regulations and/or contractual obligations
• Report suspected fraud, waste, and abuse to appropriate federal or state government regulators; accurately fill out required reporting templates
• Comply with goals, policies, procedures, and strategic plans as delegated by leadership
• Collaborate with state/federal partners, at the discretion of leadership, to include attendance at workgroups or regulatory meetings

Core Competencies

• Understand the CPT and procedural coding for dental and vision claim submissions and the client policies/benefits related to those codes
• Be able to work independently through provider investigations and deploy effective and efficient investigative strategies for each investigation as well as
• Be able to collect and secure adequate documentation in relation to dental investigations and prepare summaries of findings
• Understand what constitutes suspected provider fraud, be able to respond appropriately with notifications of key stakeholders within required timeframes
• Ability to coordinate and track overpayment recoveries, document and work with collection agency to collect when necessary; prepare end of year overpayment reports for government clients
• Data mining skills - collecting, collating, analyzing and interpreting claims data to identify aberrant provider practices and peer to peer patterns
• Understand and apply appropriate applicable federal and state regulations and/or contractual obligations in relation to fraud, waste, and abuse.

Behavioral Competencies

• Collegiality: building strong relationships on company-wide, approachable, and helpful, ability to mentor and support team growth.
• Initiative: readiness to lead or take action to achieve goals.
• Communicative: ability to relay issues, concepts, and ideas to others easily orally and in writing.
• Member-focused: going above and beyond to make our members feel seen, valued, and appreciated.
• Detail-oriented and thorough: managing and completing details of assignments without too much oversight.
• Flexible and responsive: managing new demands, changes, and situations.
• Critical Thinking: effectively troubleshoot complex issues, problem solve and multi-task.
• Integrity & responsibility: acting with a clear sense of ownership for actions, decisions and to keep information confidential when required.
• Collaborative: ability to represent your own interests while being fair to those representing other or competing ideas in search of a workable solution for all parties.

Minimum Qualifications:

• Bachelor's Degree OR 5+ years of experience in healthcare fraud, waste, and abuse investigations. High School Diploma required.
• Knowledge of fraud, waste, and abuse regulations
• Advanced level of proficiency in Microsoft Excel and Word
• 3+ years of experience in health care insurance industry
• 2+ years of experience in ICD-10, CPT or CDT coding
• Accredited Health Care Fraud Investigator (AHFI) or Certified Fraud Examiner (CFE) required
• As this role is a remote role, you are required to maintain internet service that allows you to complete your essential job duties without issue. Rates of 50 Mbps download and 10 Mbps upload while hardwired and not on a VPN are sufficient.

Preferred Qualifications:

• National Health Care Anti-Fraud Association (NHCAA)
• Certified Professional Coder (CPC)
• Registered Health Information Technician/Administrator (RHIT or RHIA)

We Offer

• Meaningful and challenging work opportunities to accelerate innovation in a secure and compliant way.
• Competitive compensation package.
• Excellent medical, dental, supplemental health, life and vision coverage for you and your dependents with no wait period.
• Life and disability insurance.
• A great 401(k) with company match.
• Tuition assistance, paid parental leave and backup family care.
• Dynamic, modern work environments that promote collaboration and creativity to develop and empower talent.
• Flexible time off, dress code, and work location policies to balance your work and life in the ways that suit you best.
• Employee Resource Groups that advocate for inclusion and diversity in all that we do.
• Social responsibility in all aspects of our work. We volunteer within our local communities, create educational alliances with colleges, drive a variety of initiatives in sustainability.

Equal Employment Opportunity

At Avsis, We See You. We celebrate differences and are building a culture of inclusivity and diversity. We are proud to be an Equal Employment Opportunity employer that considers all qualified applicants and does not discriminate against any person based on ancestry, age, citizenship, color, creed, disability, familial status, gender, gender expression, gender identity, marital status, military or veteran status, national origin, race, religion, sexual orientation, or any other characteristic. At Avsis, we believe that, to operate at the peak of excellence, our workforce needs to represent a rich mixture of diverse people, all focused on providing a world-class experience for our clients. We focus on recruiting, training and retaining those individuals that share similar goals. Come Dare to be Different at Avsis, where We See You!