HMSA is seeking an Investigator I for their Special Investigations Unit. The role involves managing fraud, waste, and abuse allegations, conducting investigations, and coordinating with various entities to resolve cases.
Responsibilities
- Manage FWA case investigations, collaborate with federal, state and law enforcement entities, and provide applicable notifications as required
- Maintain extensive documentation and evidence for SIU cases
- Recommend and implement preventive measures to combat FWA schemes including, but not limited to provider education, policies, claims edits and payment suspensions
- Manage the recovery, allocation and documentation of health plan funds resulting from FWA findings
- Manage the intake, documentation and resolution of FWA referrals to SIU
- Coordinate with internal and external partners on FWA allegations
- Assess needs, make recommendations and complete timely reviews in accordance with all regulatory requirements
- Create and maintain internal policies and procedures, workflows and presentations and present as needed to internal and external entities
- Support regulatory audits and RFIs from law enforcement and federal and state entities
- Represent SIU at cross functional workgroups and meetings and present case recommendations to other applicable business areas including, but not limited to Legal, Medical Management, Provider Operations and Claims Administration
- Perform all other miscellaneous responsibilities and duties as assigned or directed
Skills
- Bachelor's degree and one (1) year of related work experience; or equivalent combination of education and related work experience
- Fundamental knowledge/awareness of Fraud, Waste and Abuse
- Strong oral and written communication skills
- Basic working knowledge of Microsoft Word, Excel, and PowerPoint
- Intermediate working knowledge of Microsoft Outlook
Company Overview
- HMSA is an insurance company that provides affordable health plans, employee benefits services and worksite wellness programs. It was founded in 1938, and is headquartered in Honolulu, Hawaii, USA, with a workforce of 1001-5000 employees. Its website is https://www.hmsa.com.