The Internal Fraud Investigator is responsible for performing related duties and assignments to support and administer Fallon Health’s Fraud, Waste and Abuse program in conformance with established policies and procedures. Performs functions, within scope of authority and expertise, to provide the highest level of service and responsiveness of incoming referrals or case assignment. This role requires effective organizational and prioritization skills with multi-tasking ability to track day-to-day activity and follow-up on outstanding items. This role will include conducting investigations and work with other SIU Investigators or staff on suspected fraud waste and abuse. This could include medical reviews or audits that identify, evaluate and measure potential healthcare fraud waste and abuse.

The Internal Audit Department (IA) at Fallon Health (FH) is the designated Fraud, Waste and Abuse Unit for the company. As such, it’s IA’s responsibility to provide guidance and oversight regarding preventive and detective activities. IA reports administratively to the Chief Compliance Officer and functionally to the Audit & Compliance Committee and plays a key role in employing various procedures to detect fraud, waste and abuse. Under the direction of the Audit Director, the Fraud Specialists will perform the following:

• Takes initiative and works as a liaison with SIU staff, to manage the day-to-day administrative functions, which include working with SIU staff and regulatory and law enforcement agencies to support on-going investigations.
• Investigator, you will investigate suspected incidents of healthcare fraud, waste or abuse through data analysis (a high level of proficiency with Excel is required). Collaborate and partnered SIU Investigators on suspected fraud, waste and abuse, which will include planning, organize, and execute on medical reviews or audits that identify, evaluate and measure potential healthcare fraud waste and abuse.
• Conduct interviews or correspond with providers, members, vendors or other relevant parties within scope of authority or expertise.
• This will include in-house background using intranet social media and other sites and resources.
• Prepare concise investigative summaries to support findings of potential fraud, waste and abuse.
• Be responsible for the tracking of case events, status and coordinate communication to relevant parties.
• Analyze information gathered by investigation and report findings and recommendations as a written summary and/or presentation.
• Assist in related training of internal employees or departments.
• Supports legal proceedings as needed, this may include testifying in court or work with law enforcement personnel to prepare cases for civil or criminal actions.
• Assist in the tracking and logging of overpayment, settlement agreements or other payment terms to resolution.
• Maintain current knowledge of relevant laws, regulations, and standards.
• Participates in special projects as required.
• Assist in pulling metric reports and/or develop reports for regular updates to the Director of the department upper management and to business partners, regarding pending fraud investigations and fraud litigation.
• May assist in responding to various regulatory agencies complaints and may file, or assist in the filing of, fraud reports as required by state and federal agencies.
• May assist in reviewing claims or complete ad hoc projects as requested by management, and assist management on projects, as well as special requests.

• Bachelor’s Degree in related discipline, or the equivalent combination of education, professional training, and work experience.
• Preferably Healthcare backroad or prior experience in fraud.

• Preferred certifications, but not required - Certified Fraud Specialist (CFS), Certified Fraud Examiner (CFE), or Certified in Healthcare Compliance (CHC).
• Ability to obtain specific job certifications

• Four+ years of related fraud or investigative experience.
• Effective organizational and prioritization skills with multi-tasking ability, and administrative skills.
• Excellent skills in Excel.
• Excellent verbal and written communication skills.
• Strong listening and observation skills.
• Attention to detail and high level of accuracy.
• Requires a high degree of integrity and confidentiality based on exposure to information that is considered personal and confidential.
• Strong Communication and presentation skills.
• Collaboration with internal and external customers.
• Strong Analytical Ability; and Knowledge of federal and state regulations, legislation and laws, auditing reports and system functions, comparing functions with established standards.