Audit/Investigation Coordinator II

Job Summary:

Performs in-depth evaluation and makes field level judgments related to complaints and investigative leads of potential fraud investigations (e.g. Medicare and/or Medicaid) that meet established criteria for referral to the appropriate agency(ies) for administrative action or law enforcement.

Essential Functions:

• Reviews complaint data including allegations, subjects of the complaint, and facts of the complaint to ensure case tracking system is correctly populated and updated per pre-established timeframes.
• Maintains data records in the case tracking systems to ensure timely processing of cases.
• Screens incoming fraud leads by extracting information from sites related to the subject(s), utilizing a variety of resources and systems to capture the scope of fraud, and evaluating relevant legislation to draft a case file that is comprehensive and accurate.
• Confers with complainants and beneficiaries, as needed, to obtain clarification regarding complaints and to verify services to assist in drafting contact reports.
• Operates systems to obtain claims, enrollment, and provider/beneficiary information.
• Prepares intake investigation report, collecting all relevant facts, risks, and leads to recommend investigations to Lead Investigator.
• Processes requests for information (RFIs), as needed, to various contractors, reviews information upon receipt, and incorporates findings into audit/investigation file to ensure thorough audit/investigation files are delivered.
• Recommends opportunities to improve fraud audit/investigation processes and procedures ensuring industry best practices are being followed.

Level of Supervision Received:
Under close supervision, works closely with manager to prioritize efforts.

Education (can be substituted for experience):
Minimum High School Diploma or GED required

Work Experience (can be substituted for education):
2 - 4 years of experience required; 5 - 7 years preferred