Sanford Health
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Healthcare Fraud Investigator *Clinical*
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Sanford Health Careers With Purpose Sanford Health is one of the largest and fastest-growing not-for-profit health systems in the United States. We're proud to offer many development and advancement opportunities to our nearly 50,000 members of the Sanford Family who are dedicated to the work of health and healing across our broad footprint. Location Details
Facility:
Fargo Health Plan Location:
Fargo, ND Address:
1749 38th St S, Fargo, ND 58103, USA Shift:
8 Hours - Day Shifts Job Schedule:
Full time Weekly Hours:
40.00 Salary Range:
$29.00 - $46.50 Responsibilities
Responsible for conducting audits and investigations of potentially fraudulent claim activity. Plan, develop, and implement investigative processes and procedures. Conduct preliminary investigations, involving internal and external research, detailed data analyses, review of medical records, and interviews of members, providers, and other third parties. Analyze information gathered by the investigation/audit and report findings, preparing written summaries and recommendations. Conduct investigative interviews of patients and providers as necessary. Prepare evidence package for referral to third parties including contract holders, state insurance fraud bureaus and law enforcement agencies. Respond to subpoenas and requests for information from law enforcement agencies and State Departments of Insurance. May represent the company as a witness in judicial proceedings when appropriate. Perform special projects requiring expertise in fraud detection, data analytics, investigation, claim auditing and related areas. Complete reports of investigative findings and recommend investigative next steps. Identify root causes of fraud and propose internal and external corrective actions. Advise on investigative priorities, strategies, and techniques. Apply laws, regulations, plan policies and guidelines, contract provisions, coding rules, coverage rules, and industry standards to information gathered during the investigation. Share expertise and promote investigative best practices among management and staff. Educate and collaborate with various business units to raise awareness of potential concerns. Qualifications
Bachelor’s degree in health-related field or equivalent education is required. Minimum 3 years’ experience in health insurance investigation/audit. Master's Degree preferred Accredited Health Care Fraud Investigator (AHFI) certification or Certified Fraud Examiner (CFE) preferred Nursing or other clinical experience highly preferred Benefits
Sanford Health offers an attractive benefits package for qualifying full-time and part-time employees. Depending on eligibility, a variety of benefits include health insurance, dental insurance, vision insurance, life insurance, a 401(k) retirement plan, work/life balance benefits, and a generous time off package to maintain a healthy home-work balance. For more information about Total Rewards, visit https://sanfordcareers.com/benefits. Sanford is an EEO/AA Employer M/F/Disability/Vet. If you are an individual with a disability and would like to request an accommodation for help with your online application, please call 1-877-673-0854 or send an email to talent@sanfordhealth.org. Sanford Health has a Drug Free Workplace Policy. An accepted offer will require a drug screen and pre-employment background screening as a condition of employment. Req Number:
R-0233662 Job Function:
Legal and Compliance Featured:
No Seniority and Employment Type
Seniority level:
Mid-Senior level Employment type:
Full-time Job function:
Legal Industries:
Hospitals and Health Care
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Healthcare Fraud Investigator *Clinical*
role at
Sanford Health Careers With Purpose Sanford Health is one of the largest and fastest-growing not-for-profit health systems in the United States. We're proud to offer many development and advancement opportunities to our nearly 50,000 members of the Sanford Family who are dedicated to the work of health and healing across our broad footprint. Location Details
Facility:
Fargo Health Plan Location:
Fargo, ND Address:
1749 38th St S, Fargo, ND 58103, USA Shift:
8 Hours - Day Shifts Job Schedule:
Full time Weekly Hours:
40.00 Salary Range:
$29.00 - $46.50 Responsibilities
Responsible for conducting audits and investigations of potentially fraudulent claim activity. Plan, develop, and implement investigative processes and procedures. Conduct preliminary investigations, involving internal and external research, detailed data analyses, review of medical records, and interviews of members, providers, and other third parties. Analyze information gathered by the investigation/audit and report findings, preparing written summaries and recommendations. Conduct investigative interviews of patients and providers as necessary. Prepare evidence package for referral to third parties including contract holders, state insurance fraud bureaus and law enforcement agencies. Respond to subpoenas and requests for information from law enforcement agencies and State Departments of Insurance. May represent the company as a witness in judicial proceedings when appropriate. Perform special projects requiring expertise in fraud detection, data analytics, investigation, claim auditing and related areas. Complete reports of investigative findings and recommend investigative next steps. Identify root causes of fraud and propose internal and external corrective actions. Advise on investigative priorities, strategies, and techniques. Apply laws, regulations, plan policies and guidelines, contract provisions, coding rules, coverage rules, and industry standards to information gathered during the investigation. Share expertise and promote investigative best practices among management and staff. Educate and collaborate with various business units to raise awareness of potential concerns. Qualifications
Bachelor’s degree in health-related field or equivalent education is required. Minimum 3 years’ experience in health insurance investigation/audit. Master's Degree preferred Accredited Health Care Fraud Investigator (AHFI) certification or Certified Fraud Examiner (CFE) preferred Nursing or other clinical experience highly preferred Benefits
Sanford Health offers an attractive benefits package for qualifying full-time and part-time employees. Depending on eligibility, a variety of benefits include health insurance, dental insurance, vision insurance, life insurance, a 401(k) retirement plan, work/life balance benefits, and a generous time off package to maintain a healthy home-work balance. For more information about Total Rewards, visit https://sanfordcareers.com/benefits. Sanford is an EEO/AA Employer M/F/Disability/Vet. If you are an individual with a disability and would like to request an accommodation for help with your online application, please call 1-877-673-0854 or send an email to talent@sanfordhealth.org. Sanford Health has a Drug Free Workplace Policy. An accepted offer will require a drug screen and pre-employment background screening as a condition of employment. Req Number:
R-0233662 Job Function:
Legal and Compliance Featured:
No Seniority and Employment Type
Seniority level:
Mid-Senior level Employment type:
Full-time Job function:
Legal Industries:
Hospitals and Health Care
#J-18808-Ljbffr