Investigator (Full-time, Remote)

About Us http://www.integritym.com

Integrity Management Services, Inc. (IntegrityM) is an award-winning, women-owned small business specializing in assisting government and commercial clients in compliance and program integrity efforts, including the prevention and detection of fraud, waste and abuse in government programs. Results are achieved through data analytics, technology solutions, audit, investigation, and medical review.

At IntegrityM, we offer a culture of opportunity, recognition, collaboration, and supporting our community. We thrive off of these fundamental elements that make IntegrityM a great place to work. Our small, flexible workplace offers an exceptional quality of life and promotes corporate-driven sustainability. We deliver creative solutions that exceed goals and foster a dynamic, idea-driven environment that nurtures our employees’ professional development. Large company perks…Small company feel!

In this role, the Investigator will perform high level complex Medicare and Medicaid investigations and develop cases for future action, including referral to law enforcement, education, overpayment recovery and other administrative actions. The Investigator will work with internal resources and external agencies to develop cases and administrative actions as well as respond to requests for data and support. The Investigator works independently as well as collaboratively with various team members and managers.

Job Responsibilities:

Conduct thorough investigations into alleged healthcare fraud, waste, and abuse (FWA) by researching relevant offenses, reviewing records, performing interviews, and collecting evidence through observation and document examination.

Analyze investigative findings to determine whether allegations are substantiated; collaborate with colleagues, including data analysts and subject matter experts, to develop appropriate corrective actions or referrals.

Develop, document, and maintain comprehensive case files in accordance with investigative standards, including timely updates in databases and case tracking tools.

Conduct research on Medicare and Medicaid claims data and other sources of information to establish policy requirements.

Prepare detailed investigative reports that apply federal or state laws, rules, or regulations to the affected programs, clearly documenting findings to support follow-up actions or enforcement referrals.

Coordinate with internal teams and external agencies—including law enforcement, legal counsel, CMS, and state or federal investigators—on joint investigations, case development, and information-sharing efforts.

Conduct background research on suspect providers to identify adverse business relationships, sanctions, exclusions, or other disqualifying information.

Review and interpret relevant healthcare policies, regulations, and instructions to support findings and recommendations in FWA cases.

Maintain high standards in fraud case development, ensuring that evidence is properly collected, documented, and safeguarded in compliance with rules of evidence and investigative guidelines.

Perform data analysis on claims data to identify patterns or anomalies indicative of FWA; contribute insights to the development of new fraud scheme detection methodologies.

Respond to law enforcement and client requests for data, documentation, or investigative support within specified timeframes.

Reviews and approves all administrative action requests prior to submitting to CMS and provide training and mentoring.

Maintains statistics on all submitted administrative actions and maintains template documents used to submit and process administrative actions.

Conduct on-site visits and in-person interviews when required as part of investigative activities.

Requirements

• Job Qualifications: Bachelor degree in business or related field with 5-7 years experience (e.g., law enforcement investigation, statistics, data analysis).
• 6+ years investigative experience in the Healthcare industry.
• At least 3 years of experience in benefit integrity investigation/detection or a related field that demonstrates expertise in reviewing, analyzing/developing information, and making appropriate decisions.
• Knowledge of CMS Medicare Program Integrity Manual, Chapter 3 – Verifying Potential Errors and Taking Corrective Actions.
• Strong investigative skills.
• Advanced data analysis skills.
• Knowledge of medical terminology, ICD-9-CM, ICD-10-CM HCPCS level II and CPT codes. Utilizes Medicaid and Contractor guidelines for coverage determinations.
• Experience in reviewing claims for appropriate billing and medical coding requirements, performing medical review, and/or developing fraud cases.
• Certified Fraud Examiner (CFE) or Accredited Health Care Fraud Investigator (AHFI). (Preferred)
• Must pass post hire background screening checks.
• For remote work, required to have wired and/or wireless internet access.
• Ability to obtain security clearance, if required by Client/Contract