Department:Special Investigations Unit, Geisinger Health Plan
Work Type: Full Time
Conducts investigations and research relating to preventing, detecting and correcting fraud, waste and abuse (FWA) in all lines of business. Maintains a caseload and performs activities relating to intake, triage, planning, conducting, reporting and closing investigations.
Maintains an investigative caseload and performs a full range of investigative functions from case development to case closing.
Ensures investigative and other activities—such as intake, planning, research, analysis, record reviews,
interviews, coordination, reports, referrals and closing—are thorough and timely and performed in accordance with established procedures and practices and supervisory instructions.
Performs data mining, analysis and research to identify potential opportunities to investigate suspected FWA. Identifies relevant information during the referral intake and triage process; to respond to requests for information; and to enhance the progress of assigned cases and other FWA projects.
Communicates updates on cases and other projects to supervisors, managers, and other GHP departments and committees.
Assists with the preparation and delivery written documents and oral briefings and presentations on SIU cases, operations and other activities.
Ensures entries in information technology are timely, accurate and consistent with established procedures and practices.
Assists with the development and implementation of initiatives—and the completion of regulatory planning and reporting requirements—in collaboration with leadership, other departments, and external entities as appropriate.
Supports legal proceedings as necessary, including law enforcement subpoenas, data requests, and
preparation for civil or criminal actions.
Competencies and Skills:
Curious, detail-oriented and inquisitive mindset. *
Organizational and time management skills, along with an ability to skillfully handle time-sensitive projects.
Analytical, problem-solving and decision-making skills to work through challenging and complex case details. *
High degree of integrity and confidentiality required for handing information that is personal and confidential.
Strong written and verbal communication skills, including the ability to obtain information from others and deliver information in a concise, clear, and accurate manner.*
The ability to navigate and understand claims data and various databases to identify and document suspected FWA.*
Ability to work collaboratively, build coalitions and resolve conflicts, including success in managing cross-functional initiatives. *
Interpersonal skills, with the ability to listen, coach, and provide technical direction to others and to interact with tact and professionalism with all levels of the organization and external contains.*
No adverse actions pending or taken against him/her by any State or Federal licensing board or program.
Education / Experience:
Bachelor’s degree in criminal justice, legal systems, a healthcare specialty, or a related field is required.
Minimum two years of experience working in a SIU, law enforcement, insurance investigations, or a related field is required.
Prior work experience collaborating with FBI, HHS-OIG, Assistant U.S. Attorneys, MFCUs or State Attorney
Designation/certification in one or more of the following is preferred: Accredited Healthcare Fraud Investigator (AHFI), Fraud Claims Law Specialist (FCLS), Health Care Anti-Fraud Associate (HCAFA), Certified Insurance Fraud Investigator (CIFI).
Working Conditions/Physical Demands:
Work is typically performed in an office environment. Travel may be required.
Accountable for satisfying all job specific obligations and complying with all organization policies and procedures. The specific statements in this profile are not intended to be all-inclusive. They represent typical elements considered necessary to successfully perform the job.
OUR PURPOSE & VALUES: Everything we do is about caring for our patients, our members, our students, our Geisinger family and our communities. KINDNESS: We strive to treat everyone as we would hope to be treated ourselves. EXCELLENCE: We treasure colleagues who humbly strive for excellence. LEARNING: We share our knowledge with the best and brightest to better prepare the caregivers for tomorrow. INNOVATION: We constantly seek new and better ways to care for our patients, our members, our community, and the nation.
Geisinger Health Plan (GHP) is the health insurance component of Geisinger and serves over 460,000 members in Pennsylvania. Begun in 1985, GHP provides high quality, affordable health-care benefits for businesses of all sizes, individuals and families, and Medicare beneficiaries.
About Geisinger: Founded more than 100 years ago, Geisinger serves more than three million residents throughout central, south-central and northeastern Pennsylvania and southern New Jersey. Our physician-led system is comprised of 30,000 employees, including 1,600 employed physicians, and consists of 13 hospital campuses, the Geisinger Health Plan, Geisinger Commonwealth School of Medicine and two research centers.
At Geisinger, our innovative ideas are inspired by the communities we serve – like our Fresh Food
Farmacy, a program that delivers life-saving healthy alternatives to patients with diabetes. With additional tools like our MyCode Community Health Initiative, one of the first health system genome sequencing
programs, and our new asthma app suite that we developed in partnership with AstraZeneca, it’s no wonder we’re ranked one of the Top 5 Most Innovative Healthcare Systems by Becker's Hospital Review. We continually work towards continuous improvement in a culture where everyone has a voice and firmly believe that better begins with all of us.
Founded more than 100 years ago, Geisinger serves more than three million residents throughout central, south-central and northeastern Pennsylvania and southern New Jersey. Our physician-led system is comprised of 30,000 employees, including 1,600 employed physicians, and consists of 13 hospital campuses, the Geisinger Health Plan, Geisinger Commonwealth School of Medicine and two research centers.
What you do at Geisinger shapes the future of health and improves lives – for our patients, communities, and you.