SIU Fraud Investigator

Site: Mass General Brigham Health Plan Holding Company Inc.

Mass General Brigham relies on a wide range of professionals including doctors nurses business people tech experts researchers and systems analysts to advance our mission. As a not-for-profit we support patient care research teaching and community service striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham.

Job Summary

Mass General Brigham Health Plan is an exciting place to be within the healthcare industry. As a member of Mass General Brigham we are at the forefront of transformation with one of the worlds leading integrated healthcare systems. Together we are providing our members with innovative solutions centered on their health needs to expand access to seamless and affordable care and coverage.

Our work centers on creating an exceptional member experience a commitment that starts with our employees. Working with some of the most accomplished professionals in healthcare today our employees have opportunities to learn and contribute expertise within a welcoming and supportive environment that embraces their unique and varied backgrounds experiences and skills.

We are pleased to offer competitive salaries and a benefits package with flexible work options career growth opportunities and much more.

The role will be responsible for creating refining and performing various analytic reporting aimed at identifying potential fraudulent wasteful or abusive claim addition to performing analytics the Data Analyst will be required to conduct preliminary research of identified providers or members including public records contracts and social media reviews. The analyst will be accountable for documenting analytical and research activities in concise reports or memoranda.

Essential Functions
-Responsible for conducting confidential investigations of suspected fraud waste & abuse (FWA) involving medical providers plan members or other entities or individuals.
-Investigative activities include but are not limited to: data analysis public records research document review and interviewing.
-Performs case research to include the review interpretation and application of payment policies medical policies provider manuals benefits documents national or local coverage determinations and other applicable clinical practice parameters regulations or guidance pertaining to the submission of claims to health insurance plans.
-Obtains investigative evidence by requesting medical and administrative documents and by conducting interviews of providers members or other associated parties.
-Analyzes and interprets multiple sources of data including health insurance claims financial transaction information contract configurations and other materials.
-Is an expert report writer with the ability to create timely documentation including investigative plans case summaries and interview reports.
-Stays up to date with industry trends including those pertaining to prevailing fraud waste & abuse schemes.

Education

• Bachelors Degree Related Field of Study required; experience can be considered in lieu of a degree

Experience

• At least 5-7 years of experience conducting fraud waste and abuse investigations required

Knowledge Skills and Abilities

• Strong demonstrated track record of the ability to execute on time on budget and on scope.
• Strong aptitude for technology-based solutions.
• Excellent leadership skills and leadership track record.
• Ability to translate and communicate complex topics in a variety of forums.
• Excellent interpersonal skills.

Working Conditions

• This is a hybrid role that requires an on-site presence at the office in Assembly Row Somerville roughly once per month

Hybrid

399 Revolution Drive

40

Regular

Day (United States of America)

Pay Range

$79560.00 - $115720.80/Annual

Grade

7

At Mass General Brigham we believe in recognizing and rewarding the unique value each team member brings to our organization. Our approach to determining base pay is comprehensive and any offer extended will take into account your skills relevant experience if applicable education certifications and other essential factors. The base pay information provided offers an estimate based on the minimum job qualifications; however it does not encompass all elements contributing to your total compensation addition to competitive base pay we offer comprehensive benefits career advancement opportunities differentials premiums and bonuses as applicable and recognition programs designed to celebrate your contributions and support your professional growth. We invite you to apply and our Talent Acquisition team will provide an overview of your potential compensation and benefits package.

8925 Mass General Brigham Health Plan Holding Company Inc. is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race color religious creed national origin sex age gender identity disability sexual orientation military service genetic information and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process to perform essential job functions and to receive other benefits and privileges of employment. To ensure reasonable accommodation for individuals protected by Section 503 of the Rehabilitation Act of 1973 the Vietnam Veterans Readjustment Act of 1974 and Title I of the Americans with Disabilities Act of 1990 applicants who require accommodation in the job application process may contact Human Resources at .