Posted on: September 9, 2021
Your career starts now. We’re looking for the next generation of
health care leaders.
At AmeriHealth Caritas, we’re passionate about helping people get
care, stay well and build healthy communities. As one of the
nation's leaders in health care solutions, we offer our associates
the opportunity to impact the lives of millions of people through
our national footprint of products, services and award-winning
programs. AmeriHealth Caritas is seeking talented, passionate
individuals to join our team. Together we can build healthier
communities. If you want to make a difference, we’d like to hear
Headquartered in Philadelphia, AmeriHealth Caritas is a
mission-driven organization with more than 30 years of experience.
We deliver comprehensive, outcomes-driven care to those who need it
most. We offer integrated managed care products, pharmaceutical
benefit management and specialty pharmacy services, behavioral
health services, and other administrative services. Discover more
about us at www.amerihealthcaritas.com.
The Investigator is responsible for conducting comprehensive
investigations of reported, alleged or suspected fraud involving
the full range of products at the AmeriHealth Caritas Family of
Ensures compliance with all requirements related to Special
Investigation Units and fraud, waste and abuse investigations.
Performance of data-mining activities to identify potential
cases for investigation.
Performing sampling methodologies for medical record
requests/reviews (e.g., OIG SVRS tool, Probe or random
Conducts investigations of potential fraud, waste and/or
abuse with a focus on thoroughness and attention to detail,
quality, timeliness and cost control.
Conducts comprehensive interviews with providers, members and
witnesses to obtain information which would be considered
admissible under generally accepted criminal and civil rules of
Proactively performs research using the Internet, data analysis
tools, etc., to analyze aberrant claims billing and practice
Analyzes data as part of the investigative process using
available fraud detection software and corporate resources.
Represents ACFC in conducting settlement negotiations with
providers, counsel and/or other associated parties.
Prepares and submits investigative reports covering all phases
of the investigation.
Interprets and conveys highly technical information to
Establishes and maintains liaison with public officials, law
enforcement and others to obtain assistance in conducting
Bachelor’s Degree preferred.
Valid driver’s license required.
Ability to work independently with minimal supervision, and
manage a high volume of assignments.
Strong verbal and written communication skills.
High degree of integrity and confidentiality required handling
information that is considered personal and confidential.
Analytical skills and ability to make deductions; logical and
A minimum of 3-5 years experience conducting comprehensive
health care fraud investigations; interacting with state,
federal and local law enforcement agencies.
Health care industry and/or
Medicare/Medicaid/Pharmacy/Behavioral Health/Pharmacy Benefit
Management knowledge required.
SIU and/or State Medicaid regulatory compliance work
Knowledge and proficiency in claims adjudication
standards & procedures preferred.
Solid knowledge of Medicaid, Medicare, and pharmacy benefit
laws and requirements; federal, state, civil and criminal
Experience with decision support tools used for data
Advanced knowledge and experience working on various approaches
to fraud, waste and abuse.
Working knowledge of Microsoft applications, especially Excel
Knowledge of available resources (internal and external) to
assist in investigations.
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