Detectives and Criminal Investigators

At U.S. Bank, we’re on a journey to do our best. Helping the customers and businesses we serve to make better and smarter financial decisions and enabling the communities we support to grow and succeed. We believe it takes all of us to bring our shared ambition to life, and each person is unique in their potential. A career with U.S. Bank gives you a wide, ever-growing range of opportunities to discover what makes you thrive at every stage of your career. Try new things, learn new skills and discover what you excel at—all from Day One.

**Job Description**

Partners with leaders in their assigned Line of Business, Risk/Compliance/Audit (RCA) Consultants, and other RCA Managers to, depending on the function, oversee the successful creation, implementation, and maintenance of an effective risk management framework. Lead projects and/or activities that ensure compliance with applicable federal, state, and local laws and regulations. Facilitate the identification of gaps and drive solutions that minimize losses resulting from inadequate internal processes, systems, or human errors. Ensures the active identification, response and/or escalation of risks as appropriate. May influence policies and procedures to maximize profit potential and minimize regulatory exposure. Accountable for an effective partnership between the Line of Business and the Lines of Defense.

**Basic Qualifications**

- Bachelor's degree, or equivalent work experience

- Typically, more than six years of applicable experience

**Preferred Skills/Experience**

- Advanced knowledge of applicable laws, regulations, financial services, and regulatory trends that impact their assigned line of business

- Advanced understanding of the business line’s operations, products/services, systems, and associated risks/controls

- Thorough knowledge of Risk/Compliance/Audit competencies

- Strong leadership and management skills of processes, projects and people

- Effective written and verbal communication skills

- Strong analytical, problem-solving and negotiation skills

- Proficient computer skills, especially Microsoft Office applications

- Applicable professional certifications

**Additional Job Description**

This role leads a complex fraud investigation team that is responsible for conducting fraud ring and high-risk and sensitive investigations spanning all products and services offered by U.S. Bank including broker-dealer products. This team also works joint investigations with AML Investigations.

**Beyond traditional fraud investigations experience, the candidate must have 5+ years of broker-dealer and AML investigative experience.**

**_The role offers a hybrid/flexible schedule, which means there's an in-office expectation of 3 or more days per week and the flexibility to work outside the office location for the other days._**

If there’s anything we can do to accommodate a disability during any portion of the application or hiring process, please refer to our disability accommodations for applicants (https://careers.usbank.com/global/en/disability-accommodations-for-applicants) .

**Benefits:**

Our approach to benefits and total rewards considers our team members’ whole selves and what may be needed to thrive in and outside work. That's why our benefits are designed to help you and your family boost your health, protect your financial security and give you peace of mind. Our benefits include the following (some may vary based on role, location or hours):

+ Healthcare (medical, dental, vision)

+ Basic term and optional term life insurance

+ Short-term and long-term disability

+ Pregnancy disability and parental leave

+ 401(k) and employer-funded retirement plan

+ Paid vacation (from two to five weeks depending on salary grade and tenure)

+ Up to 11 paid holiday opportunities

+ Adoption assistance

+ Sick and Safe Leave accruals of one hour for every 30 worked, up to 80 hours per calendar year unless otherwise provided by law

**EEO is the Law**

U.S. Bank is an equal opportunity employer committed to creating a diverse workforce. We consider all qualified applicants without regard to race, religion, color, sex, national origin, age, sexual orientation, gender identity, disability or veteran status, among other factors. Applicants can learn more about the company’s status as an equal opportunity employer by viewing the federal **KNOW YOUR RIGHTS (https://eeoc.gov/sites/default/files/2023-06/22-088\_EEOC\_KnowYourRights6.12ScreenRdr.pdf)** EEO poster.

**E-Verify**

U.S. Bank participates in the U.S. Department of Homeland Security E-Verify program in all facilities located in the United States and certain U.S. territories. The E-Verify program is an Internet-based employment eligibility verification system operated by the U.S. Citizenship and Immigration Services. Learn more about the E-Verify program (https://careers.usbank.com/verification-of-eligibility-for-employment) .

The salary range reflects figures based on the primary location, which is listed first. The actual range for the role may differ based on the location of the role. In addition to salary, U.S. Bank offers a comprehensive benefits package, including incentive and recognition programs, equity stock purchase 401(k) contribution and pension (all benefits are subject to eligibility requirements). Pay Range: $98,175.00 - $115,500.00 - $127,050.00

U.S. Bank will consider qualified applicants with arrest or conviction records for employment. U.S. Bank conducts background checks consistent with applicable local laws, including the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act as well as the San Francisco Fair Chance Ordinance. U.S. Bank is subject to, and conducts background checks consistent with the requirements of Section 19 of the Federal Deposit Insurance Act (FDIA). In addition, certain positions may also be subject to the requirements of FINRA, NMLS registration, Reg Z, Reg G, OFAC, the NFA, the FCPA, the Bank Secrecy Act, the SAFE Act, and/or federal guidelines applicable to an agreement, such as those related to ethics, safety, or operational procedures.

Applicants must be able to comply with U.S. Bank policies and procedures including the Code of Ethics and Business Conduct and related workplace conduct and safety policies.

Job postings typically remain open for approximately 20 days of the posting date listed above, however the job posting may be closed earlier should it be determined the position is no longer required due to business need. Job postings in areas with a high volume of applicants, such as customer service, contact center, and Financial Crimes investigations, remain open for approximately 5 days of the posting listed date.

**Your Future Evolves Here**

Evolent partners with health plans and providers to achieve better outcomes for people with most complex and costly health conditions. Working across specialties and primary care, we seek to connect the pieces of fragmented health care system and ensure people get the same level of care and compassion we would want for our loved ones.

Evolent employees enjoy work/life balance, the flexibility to suit their work to their lives, and autonomy they need to get things done. We believe that people do their best work when they're supported to live their best lives, and when they feel welcome to bring their whole selves to work. That's one reason why diversity and inclusion are core to our business.

Join Evolent for the mission. Stay for the culture.

**What You’ll Be Doing:**

Put your passion where it meets purpose! Evolent attracts some of the brightest minds in health care. Surround yourself with talented, driven colleagues who share a passion for better health outcomes and a more connected care journey. We are hiring for an Investigator to join our Special Investigations Unit.

Evolent’s Special Investigation Unit works closely with our health plan clients to identify, reduce and eliminate health care fraud, waste and abuse.

**Collaboration Opportunities:**

As an investigator with Evolent’s Special Investigations Unit, you will have the opportunity to work closely with the Operations Team, Compliance, Utilization Management, and our partners at State Agencies and Law Enforcement. Our team of investigators work together to identify current fraud schemes, perform data analytics, conduct audits and educate providers.

**What You’ll Be Doing:**

• Performing target claim audits (desk and on-site) as directed; distributing audit reports by the required due date

• Conducting investigations, including but not limited to, data analysis, record review, provider office inspections, and field observations

• Communicating audit findings internally to the Special Investigations Unit, executive leadership and state or federal regulatory entities as needed

• Serving as an integral attendee and contributor at Special Investigations Unit meetings

• Gathering and reviewing data in response to inquiries sent to the Special Investigations Unit

• Handling Fraud, Waste, and Abuse (FWA) hotline calls and e-mails, responding to messages received and tracking receipt of calls and e-mails

• Assisting in development and implementation of FWA policies and procedures

• Maintaining up-to-date notes and documentation on respective case load in the Investigation Database

• Assisting in planning, development, and delivery of FWA related educational training for the company and providers

• Acting as the Special Investigations Unit Liaison to assigned company departments to provide educational information and soliciting feedback

• Maintaining confidentiality of all sensitive investigative/audit information

• Performing other duties and projects as assigned

**Qualifications – Required and Preferred:**

• Bachelor’s degree preferred

• 1-2 years of experience in FWA investigating in a healthcare operation

• Knowledge of corporate investigative practices

• Proficient understanding of medical terminology, human anatomy, medical tests and procedures, and health conditions

• Leadership skills to effectively communicate with staff and regulatory representatives

• Investigative, decision-making, problem solving, interpersonal and organizational skills

• Consistent demonstration of accuracy, thoroughness and timeliness in completing work assignments; detail-oriented

• Excellent ability to plan, organize and maintain multiple projects and files

• Excellent verbal and written communication skills and interpersonal skills

• Proficient experience using Outlook, Word, Excel and PowerPoint in a Windows operating system

• Ability to adapt to fluctuating situations

• Preferred 3-5 years of experience in FWA investigating in a healthcare operation

• Preferred knowledge of healthcare services coding and claims billing

• Preferred knowledge of Health Insurance, Managed Care, Benefit Design, and Federal Regulations

• Preferred AHFI, CFE, and/or Certified Coder with either CPC, CCS or CMPA (*Certified Professional Coder, Certified Coding Specialist, Certified Professional Medical Auditor)

**Technical Requirements:**

We require that all employees have the following technical capability at their home: High speed internet over 10 Mbps and, specifically for all call center employees, the ability to plug in directly to the home internet router. These at-home technical requirements are subject to change with any scheduled re-opening of our office locations.

**Evolent is an equal opportunity employer and considers all qualified applicants equally without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran status, or disability status.** **If you need reasonable accommodation to access the information provided on this website, please contact** **[email protected]** **for further assistance.**

The expected base salary/wage range for this position is $85,000. This position is also eligible for a bonus component that would be dependent on pre-defined performance factors. As part of our total compensation package, Evolent is proud to offer comprehensive benefits (including health insurance benefits) to qualifying employees. All compensation determinations are based on the skills and experience required for the position and commensurate with experience of selected individuals, which may vary above and below the stated amounts.

Don't see the dream job you are looking for? Drop off your contact information and resume and we will reach out to you if we find the perfect fit!

Bring your heart to CVS Health. Every one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand — with heart at its center — our purpose sends a personal message that how we deliver our services is just as important as what we deliver.

Our Heart At Work Behaviors™ support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable.

**Position Summary**

We are seeking an experienced Senior Healthcare Fraud Investigator to join our Special Investigations Unit (Aetna SIU). In this role, you will manage complex investigations into suspected and known acts of healthcare fraud, waste and abuse (FWA).

**Key Responsibilities**

+ Conduct high level, complex investigations of known or suspected acts of healthcare fraud, waste and abuse.

+ Conduct Investigations to prevent payment of suspect or fraudulent claims submitted by insured's, providers, claimants, and customers.

+ Researches and prepares cases for clinical and legal review.

+ Documents all appropriate case activity in case tracking system.

+ Prepare written case summaries and make referrals to State and Federal Agencies within the timeframes required by Law.

+ Facilitates the recovery of company and customer money lost as a result of fraud, waste and abuse.

+ Cooperates with federal, state, and local law enforcement agencies in the investigation and prosecution of healthcare fraud.

+ Demonstrates high level of knowledge and expertise during interactions with internal and external partners.

+ Provide Trial Testimony in support of Criminal or Civil proceedings.

+ Gives presentations to internal and external customers regarding ongoing case investigations.

+ Exercises independent judgment and uses available resources and technology to develop evidence in support of case investigations.

**Required Qualifications**

+ 3-5 years investigative experience in the area of healthcare fraud, waste and abuse.

+ Proficiency in Word, Excel, MS Outlook products, open source database search tools, social media and internet research.

+ Ability to travel up to 25% of time for business purposes.

**Preferred Qualifications**

+ Strong communication and customer service skills and the ability to effectively interact with Aetna's customers.

+ Certified Professional Coder (CPC), AHFI, or CFE

+ Bilingual: English/Spanish

**Education**

+ Bachelor's Degree or equivalent professional experience.

**Anticipated Weekly Hours**

40

**Time Type**

Full time

**Pay Range**

The typical pay range for this role is:

$46,988.00 - $112,200.00

This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.

In addition to your compensation, enjoy the rewards of an organization that puts our heart into caring for our colleagues and our communities. The Company offers a full range of medical, dental, and vision benefits. Eligible employees may enroll in the Company’s 401(k) retirement savings plan, and an Employee Stock Purchase Plan is also available for eligible employees. The Company provides a fully-paid term life insurance plan to eligible employees, and short-term and long term disability benefits. CVS Health also offers numerous well-being programs, education assistance, free development courses, a CVS store discount, and discount programs with participating partners. As for time off, Company employees enjoy Paid Time Off (“PTO”) or vacation pay, as well as paid holidays throughout the calendar year. Number of paid holidays, sick time and other time off are provided consistent with relevant state law and Company policies.

For more detailed information on available benefits, please visit Benefits | CVS Health (https://jobs.cvshealth.com/us/en/benefits)

We anticipate the application window for this opening will close on: 03/13/2025

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

We are an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring, promotion, or any other personnel action based on race, ethnicity, color, national origin, sex/gender, sexual orientation, gender identity or expression, religion, age, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law.

Bring your heart to CVS Health. Every one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand — with heart at its center — our purpose sends a personal message that how we deliver our services is just as important as what we deliver.

Our Heart At Work Behaviors™ support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable.

**Position Summary**

+ This position can be work from home anywhere in the United States. Must be flexible to work EDT hours (8:00 am - 5 pm EDT)

+ Conducts investigations to effectively pursue the prevention, detection, investigation and prosecution of healthcare fraud, waste, and abuse. Also reports suspected fraud, waste, and abuse to state and federal agencies as required by law and regulation.

**Fundamental Components**

+ Conducts investigations of known or suspected acts of healthcare fraud, waste, and abuse

+ Communicates with federal, state, and local law enforcement agencies as appropriate in matters pertaining to the prosecution of specific healthcare fraud cases

+ Investigates to prevent payment of fraudulent, abusive, or otherwise improperly billed claims submitted by providers, members, and others

+ Facilitates the recovery of company and customer monetary losses

+ Provides input regarding controls for preventing or monitoring fraud related issues within the business units

+ Delivers educational programs designed to promote deterrence and detection of fraud and minimize losses to the company

+ Maintains open communication with constituents within and external to the company

+ Uses available resources and technology in developing evidence, supporting allegations of fraud, waste, and abuse

+ Researches and prepares cases for clinical and legal review

+ Documents all appropriate case activity in tracking system

+ Makes referrals, both internal and external, in the required timeframe

+ Exhibits behaviors outlined in Employee Competencies

+ Exhibits behaviors outlined in SIU Investigator Competencies

**Required Qualifications**

+ 1-3 years of investigative experience in the area of healthcare fraud, waste and abuse

+ Ability to travel up to 25% to testify in court proceedings or trainings if necessary.

+ Strong knowledge of medical terminology/CPT/HCPCS coding.

+ Advanced skills with Microsoft Excel

+ Experience in healthcare/medical insurance claims investigation or professional/clinical experience

+ Background with law enforcement agencies involving economic or insurance related matters; or professional investigation experience involving economic or insurance related matters; or an authorized medical professional to evaluate medical related claims

+ Proficiency in Word, MS Outlook products, Database search tools, and use in the Intranet/Internet to research information

**Preferred Qualifications**

+ AHFI, CFE, Certified Professional Coder

+ Knowledge of CVS/Aetna's policies and procedures

+ Strong analytical and research skills

+ Proficient in researching information and identifying information resources

+ Strong verbal and written communication skills

+ Strong customer service skills

+ Ability to interact with different groups of people at different levels and provide assistance on a timely basis

**Education**

+ College degree in Criminal Justice or related field

**Anticipated Weekly Hours**

40

**Time Type**

Full time

**Pay Range**

The typical pay range for this role is:

$43,888.00 - $93,574.00

This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.

In addition to your compensation, enjoy the rewards of an organization that puts our heart into caring for our colleagues and our communities. The Company offers a full range of medical, dental, and vision benefits. Eligible employees may enroll in the Company’s 401(k) retirement savings plan, and an Employee Stock Purchase Plan is also available for eligible employees. The Company provides a fully-paid term life insurance plan to eligible employees, and short-term and long term disability benefits. CVS Health also offers numerous well-being programs, education assistance, free development courses, a CVS store discount, and discount programs with participating partners. As for time off, Company employees enjoy Paid Time Off (“PTO”) or vacation pay, as well as paid holidays throughout the calendar year. Number of paid holidays, sick time and other time off are provided consistent with relevant state law and Company policies.

For more detailed information on available benefits, please visit Benefits | CVS Health (https://jobs.cvshealth.com/us/en/benefits)

We anticipate the application window for this opening will close on: 03/13/2025

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

We are an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring, promotion, or any other personnel action based on race, ethnicity, color, national origin, sex/gender, sexual orientation, gender identity or expression, religion, age, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law.

Advance Your Career in Insurance Claims with Allied Universal® Compliance and Investigation Services. Allied Universal® Compliance and Investigation Services is the premier destination for a career in insurance claim investigation. As a global leader, we provide dynamic opportunities for claim investigators, SIU investigators, and surveillance investigators. Our diverse and inclusive team is committed to innovation and excellence, making a significant impact in the insurance industry. If you’re ready to grow with the best, explore a career with us and make a difference. Enjoy comprehensive benefits for most full-time positions, including medical, dental, and vision coverage, life insurance, retirement plans, employee assistance programs, and exclusive perks.

Allied Universal® is hiring a Surveillance Investigator. Surveillance Investigators perform discreet mobile and stationary surveillance of Claimant to confirm current activities and capabilities to assist with the administration of an Insurance claim.

+ **Opportunity awaits – apply now!**

+ **Job flexibility offering fieldwork!**

+ **Auto and travel allowances!**

**RESPONSIBILITIES:**

+ Conduct independent investigations of insurance claims across a range of coverage types, including workers’ compensation, general liability, property and casualty, and disability

+ Utilize various surveillance techniques and equipment to monitor subjects covertly

+ Document and report observations, activities, and any relevant information in a clear and concise manner

+ Collaborate with other investigators and law enforcement agencies as needed to gather information and coordinate efforts

+ Maintain confidentiality and adhere to legal and ethical standards in conducting surveillance operations

**QUALIFICATIONS (MUST HAVE):**

+ High school diploma or equivalent

+ Post offer, must be able to successfully complete the Allied Universal Investigations' training/orientation course

+ Prior experience in insurance or investigations

+ Flexibility to work varied and irregular hours/days including weekends and holidays

+ Ability to type reports in Microsoft Word format with minimal grammatical and punctuation errors

+ Proficient in utilizing laptop computers, video cameras and cell phones

+ Capable of maintaining focus and multitasking effectively in a dynamic environment

+ Demonstrated ability to manage stressful situations with composure and professionalism

+ Ability to work in a very independent environment

**PREFERRED QUALIFICATIONS (NICE TO HAVE):**

+ Military experience

+ Law enforcement

+ Insurance administration experience

+ College degree in Criminal Justice

+ Two (2) or more years of experience in insurance or investigations

**BENEFITS:**

+ Medical, dental, vision, basic life, AD&D, and disability insurance

+ Enrollment in our company’s 401(k)plan, subject to eligibility requirements

+ Seven paid holidays annually, sick days available where required by law

+ Vacation time offered at an initial accrual rate of 3.08 hours biweekly for full time positions. Unused vacation is only paid out where required by law

**Allied Universal® is an Equal Opportunity Employer.** All qualified applicants will receive consideration for employment without regard to race/ethnicity, age, color, religion, sex, sexual orientation, gender identity, national origin, genetic information, disability, protected veteran status or relationship/association with a protected veteran, or any other basis or characteristic protected by law. For more information: www.aus.com

If you have any questions regarding Equal Employment Opportunity, Affirmative Action, Diversity and Inclusion, have difficulty using the online system and require an alternate method to apply, or require an accommodation at any time during the recruitment and/or employment process, please contact our local Human Resources department. To find an office near you, please visit: www.aus.com/offices .

**Allied Universal® is an Equal Opportunity Employer.** All qualified applicants will receive consideration for employment without regard to race/ethnicity, age, color, religion, sex, sexual orientation, gender identity, national origin, genetic information, disability, protected veteran status or relationship/association with a protected veteran, or any other basis or characteristic protected by law. For more information: www.aus.com

If you have any questions regarding Equal Employment Opportunity, Affirmative Action, Diversity and Inclusion, have difficulty using the online system and require an alternate method to apply, or require an accommodation at any time during the recruitment and/or employment process, please contact our local Human Resources department. To find an office near you, please visit: www.aus.com/offices .

**Job ID:** 2025-1341792

**Location:** United States-Arizona-Prescott Valley

**Job Category:** Compliance & Investigations

**JOB DESCRIPTION**

**Job Summary**

Under direct supervision of the Manager, SIU, the Team Lead is responsible to lead a small team of investigators and provide oversight on daily investigative activities as a back-up to the SIU Manager. This position will be accountable for tracking on investigations conducted by his/her team and will provide oversight and guidance throughout the life of an investigation as well as QA reviews and approvals. In addition to leading a team of investigators and analysts, the Team Lead will ensure the Manager is aware of any major case developments, and ensure cases are being investigated according to the SIU's standards. Position must have thorough knowledge of Medicaid/Medicare/Marketplace health coverage audit policies and be able to apply them in ensuring program compliance via payment integrity programs. The position must have the ability to determine correct coding, documentation, potential fraud, abuse, and over utilization by providers and recipients. The position will review claims data, medical records, and billing data from all types of healthcare providers that bill Medicaid/Medicare/Marketplace.

**KNOWLEDGE/SKILLS/ABILITIES**

+ Ensure investigators are managing their cases effectively and in accordance with SIU policies, processes, quality standards, and procedures.

+ Ensure that investigators are managing their respective State Reporting requirements and assignments effectively and timely.

+ Manage the flow of day-to-day investigations.

+ Perform assessment that QA measures were complete and signed-off

+ Provide guidance to investigators as needed on investigative techniques, tools, or strategy.

+ Effectively investigate and manage complex and non-complex fraud allegations.

+ Develop and maintain relationships with key business units within specific product line and geographic region.

+ Provides direction, instructions, and guidance to Investigative team, particularly in the absence of the SIU Manager.

+ Provide training to team members as needed.

+ Communicate clear instructions to team members, listen to team members' feedback.

+ Monitor team members' participation to ensure the training provided is effective, and if any additional training is needed.

+ Create, edit, and update assigned reports to apprise the company on the team's progress.

+ Distribute reports to the appropriate personnel.

**JOB QUALIFICATIONS**

**Required Education**

High School/GED.

**Required Experience**

+ 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 sequential thinker.

+ 2+ years of experience conducting comprehensive healthcare fraud investigations; interacting with state, federal and local law enforcement agencies, as necessary.

+ SIU Process/Systems Expertise.

+ MCO Experience.

+ Fraud Investigation Subject Matter Expert (SME).

+ Proficient knowledge and experience in the Fraud, Waste, and Abuse field.

+ Knowledge and experience in Medicaid/Medicare/Marketplace healthcare.

+ Knowledge of healthcare coding, billing and Medicaid/Medicare/Marketplace policy, Federal regulation and/or State laws, rules, and guidelines.

+ Demonstrated proficiency in analyzing the quality and necessity of health care services (inpatient and community based) and communicate results effectively.

+ Proficiency in research, understanding, interpreting and application of government rules/regulations/policies

+ Ability to conduct research, gather information and analyze a variety of data.

+ Strong computer skills required, including working knowledge of the usage of E-mail, MS word and Excel; strong communication skills, both oral and written; prior experience in a leadership role desired.

+ Required License, Certification, Association

+ Healthcare Anti-Fraud Associate (HCAFA), Accredited Health Care Fraud Examiner (AHFI) and/or Certified Fraud Examiner (CFE) preferred.

+ Valid driver’s license required.

To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

Pay Range: $24 - $56.17 / HOURLY

*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

**JOB DESCRIPTION**

**Job Summary**

Under direct supervision of the Manager, SIU, the Team Lead is responsible to lead a small team of investigators and provide oversight on daily investigative activities as a back-up to the SIU Manager. This position will be accountable for tracking on investigations conducted by his/her team and will provide oversight and guidance throughout the life of an investigation as well as QA reviews and approvals. In addition to leading a team of investigators and analysts, the Team Lead will ensure the Manager is aware of any major case developments, and ensure cases are being investigated according to the SIU's standards. Position must have thorough knowledge of Medicaid/Medicare/Marketplace health coverage audit policies and be able to apply them in ensuring program compliance via payment integrity programs. The position must have the ability to determine correct coding, documentation, potential fraud, abuse, and over utilization by providers and recipients. The position will review claims data, medical records, and billing data from all types of healthcare providers that bill Medicaid/Medicare/Marketplace.

**KNOWLEDGE/SKILLS/ABILITIES**

+ Ensure investigators are managing their cases effectively and in accordance with SIU policies, processes, quality standards, and procedures.

+ Ensure that investigators are managing their respective State Reporting requirements and assignments effectively and timely.

+ Manage the flow of day-to-day investigations.

+ Perform assessment that QA measures were complete and signed-off

+ Provide guidance to investigators as needed on investigative techniques, tools, or strategy.

+ Effectively investigate and manage complex and non-complex fraud allegations.

+ Develop and maintain relationships with key business units within specific product line and geographic region.

+ Provides direction, instructions, and guidance to Investigative team, particularly in the absence of the SIU Manager.

+ Provide training to team members as needed.

+ Communicate clear instructions to team members, listen to team members' feedback.

+ Monitor team members' participation to ensure the training provided is effective, and if any additional training is needed.

+ Create, edit, and update assigned reports to apprise the company on the team's progress.

+ Distribute reports to the appropriate personnel.

**JOB QUALIFICATIONS**

**Required Education**

High School/GED.

**Required Experience**

+ 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 sequential thinker.

+ 2+ years of experience conducting comprehensive healthcare fraud investigations; interacting with state, federal and local law enforcement agencies, as necessary.

+ SIU Process/Systems Expertise.

+ MCO Experience.

+ Fraud Investigation Subject Matter Expert (SME).

+ Proficient knowledge and experience in the Fraud, Waste, and Abuse field.

+ Knowledge and experience in Medicaid/Medicare/Marketplace healthcare.

+ Knowledge of healthcare coding, billing and Medicaid/Medicare/Marketplace policy, Federal regulation and/or State laws, rules, and guidelines.

+ Demonstrated proficiency in analyzing the quality and necessity of health care services (inpatient and community based) and communicate results effectively.

+ Proficiency in research, understanding, interpreting and application of government rules/regulations/policies

+ Ability to conduct research, gather information and analyze a variety of data.

+ Strong computer skills required, including working knowledge of the usage of E-mail, MS word and Excel; strong communication skills, both oral and written; prior experience in a leadership role desired.

+ Required License, Certification, Association

+ Healthcare Anti-Fraud Associate (HCAFA), Accredited Health Care Fraud Examiner (AHFI) and/or Certified Fraud Examiner (CFE) preferred.

+ Valid driver’s license required.

To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

Pay Range: $24 - $56.17 / HOURLY

*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

**JOB DESCRIPTION**

**Job Summary**

Under direct supervision of the Manager, SIU, the Team Lead is responsible to lead a small team of investigators and provide oversight on daily investigative activities as a back-up to the SIU Manager. This position will be accountable for tracking on investigations conducted by his/her team and will provide oversight and guidance throughout the life of an investigation as well as QA reviews and approvals. In addition to leading a team of investigators and analysts, the Team Lead will ensure the Manager is aware of any major case developments, and ensure cases are being investigated according to the SIU's standards. Position must have thorough knowledge of Medicaid/Medicare/Marketplace health coverage audit policies and be able to apply them in ensuring program compliance via payment integrity programs. The position must have the ability to determine correct coding, documentation, potential fraud, abuse, and over utilization by providers and recipients. The position will review claims data, medical records, and billing data from all types of healthcare providers that bill Medicaid/Medicare/Marketplace.

**KNOWLEDGE/SKILLS/ABILITIES**

+ Ensure investigators are managing their cases effectively and in accordance with SIU policies, processes, quality standards, and procedures.

+ Ensure that investigators are managing their respective State Reporting requirements and assignments effectively and timely.

+ Manage the flow of day-to-day investigations.

+ Perform assessment that QA measures were complete and signed-off

+ Provide guidance to investigators as needed on investigative techniques, tools, or strategy.

+ Effectively investigate and manage complex and non-complex fraud allegations.

+ Develop and maintain relationships with key business units within specific product line and geographic region.

+ Provides direction, instructions, and guidance to Investigative team, particularly in the absence of the SIU Manager.

+ Provide training to team members as needed.

+ Communicate clear instructions to team members, listen to team members' feedback.

+ Monitor team members' participation to ensure the training provided is effective, and if any additional training is needed.

+ Create, edit, and update assigned reports to apprise the company on the team's progress.

+ Distribute reports to the appropriate personnel.

**JOB QUALIFICATIONS**

**Required Education**

High School/GED.

**Required Experience**

+ 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 sequential thinker.

+ 2+ years of experience conducting comprehensive healthcare fraud investigations; interacting with state, federal and local law enforcement agencies, as necessary.

+ SIU Process/Systems Expertise.

+ MCO Experience.

+ Fraud Investigation Subject Matter Expert (SME).

+ Proficient knowledge and experience in the Fraud, Waste, and Abuse field.

+ Knowledge and experience in Medicaid/Medicare/Marketplace healthcare.

+ Knowledge of healthcare coding, billing and Medicaid/Medicare/Marketplace policy, Federal regulation and/or State laws, rules, and guidelines.

+ Demonstrated proficiency in analyzing the quality and necessity of health care services (inpatient and community based) and communicate results effectively.

+ Proficiency in research, understanding, interpreting and application of government rules/regulations/policies

+ Ability to conduct research, gather information and analyze a variety of data.

+ Strong computer skills required, including working knowledge of the usage of E-mail, MS word and Excel; strong communication skills, both oral and written; prior experience in a leadership role desired.

+ Required License, Certification, Association

+ Healthcare Anti-Fraud Associate (HCAFA), Accredited Health Care Fraud Examiner (AHFI) and/or Certified Fraud Examiner (CFE) preferred.

+ Valid driver’s license required.

To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

Pay Range: $24 - $56.17 / HOURLY

*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

**JOB DESCRIPTION**

**Job Summary**

Under direct supervision of the Manager, SIU, the Team Lead is responsible to lead a small team of investigators and provide oversight on daily investigative activities as a back-up to the SIU Manager. This position will be accountable for tracking on investigations conducted by his/her team and will provide oversight and guidance throughout the life of an investigation as well as QA reviews and approvals. In addition to leading a team of investigators and analysts, the Team Lead will ensure the Manager is aware of any major case developments, and ensure cases are being investigated according to the SIU's standards. Position must have thorough knowledge of Medicaid/Medicare/Marketplace health coverage audit policies and be able to apply them in ensuring program compliance via payment integrity programs. The position must have the ability to determine correct coding, documentation, potential fraud, abuse, and over utilization by providers and recipients. The position will review claims data, medical records, and billing data from all types of healthcare providers that bill Medicaid/Medicare/Marketplace.

**KNOWLEDGE/SKILLS/ABILITIES**

+ Ensure investigators are managing their cases effectively and in accordance with SIU policies, processes, quality standards, and procedures.

+ Ensure that investigators are managing their respective State Reporting requirements and assignments effectively and timely.

+ Manage the flow of day-to-day investigations.

+ Perform assessment that QA measures were complete and signed-off

+ Provide guidance to investigators as needed on investigative techniques, tools, or strategy.

+ Effectively investigate and manage complex and non-complex fraud allegations.

+ Develop and maintain relationships with key business units within specific product line and geographic region.

+ Provides direction, instructions, and guidance to Investigative team, particularly in the absence of the SIU Manager.

+ Provide training to team members as needed.

+ Communicate clear instructions to team members, listen to team members' feedback.

+ Monitor team members' participation to ensure the training provided is effective, and if any additional training is needed.

+ Create, edit, and update assigned reports to apprise the company on the team's progress.

+ Distribute reports to the appropriate personnel.

**JOB QUALIFICATIONS**

**Required Education**

High School/GED.

**Required Experience**

+ 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 sequential thinker.

+ 2+ years of experience conducting comprehensive healthcare fraud investigations; interacting with state, federal and local law enforcement agencies, as necessary.

+ SIU Process/Systems Expertise.

+ MCO Experience.

+ Fraud Investigation Subject Matter Expert (SME).

+ Proficient knowledge and experience in the Fraud, Waste, and Abuse field.

+ Knowledge and experience in Medicaid/Medicare/Marketplace healthcare.

+ Knowledge of healthcare coding, billing and Medicaid/Medicare/Marketplace policy, Federal regulation and/or State laws, rules, and guidelines.

+ Demonstrated proficiency in analyzing the quality and necessity of health care services (inpatient and community based) and communicate results effectively.

+ Proficiency in research, understanding, interpreting and application of government rules/regulations/policies

+ Ability to conduct research, gather information and analyze a variety of data.

+ Strong computer skills required, including working knowledge of the usage of E-mail, MS word and Excel; strong communication skills, both oral and written; prior experience in a leadership role desired.

+ Required License, Certification, Association

+ Healthcare Anti-Fraud Associate (HCAFA), Accredited Health Care Fraud Examiner (AHFI) and/or Certified Fraud Examiner (CFE) preferred.

+ Valid driver’s license required.

To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

Pay Range: $24 - $56.17 / HOURLY

*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

**JOB DESCRIPTION**

**Job Summary**

Under direct supervision of the Manager, SIU, the Team Lead is responsible to lead a small team of investigators and provide oversight on daily investigative activities as a back-up to the SIU Manager. This position will be accountable for tracking on investigations conducted by his/her team and will provide oversight and guidance throughout the life of an investigation as well as QA reviews and approvals. In addition to leading a team of investigators and analysts, the Team Lead will ensure the Manager is aware of any major case developments, and ensure cases are being investigated according to the SIU's standards. Position must have thorough knowledge of Medicaid/Medicare/Marketplace health coverage audit policies and be able to apply them in ensuring program compliance via payment integrity programs. The position must have the ability to determine correct coding, documentation, potential fraud, abuse, and over utilization by providers and recipients. The position will review claims data, medical records, and billing data from all types of healthcare providers that bill Medicaid/Medicare/Marketplace.

**KNOWLEDGE/SKILLS/ABILITIES**

+ Ensure investigators are managing their cases effectively and in accordance with SIU policies, processes, quality standards, and procedures.

+ Ensure that investigators are managing their respective State Reporting requirements and assignments effectively and timely.

+ Manage the flow of day-to-day investigations.

+ Perform assessment that QA measures were complete and signed-off

+ Provide guidance to investigators as needed on investigative techniques, tools, or strategy.

+ Effectively investigate and manage complex and non-complex fraud allegations.

+ Develop and maintain relationships with key business units within specific product line and geographic region.

+ Provides direction, instructions, and guidance to Investigative team, particularly in the absence of the SIU Manager.

+ Provide training to team members as needed.

+ Communicate clear instructions to team members, listen to team members' feedback.

+ Monitor team members' participation to ensure the training provided is effective, and if any additional training is needed.

+ Create, edit, and update assigned reports to apprise the company on the team's progress.

+ Distribute reports to the appropriate personnel.

**JOB QUALIFICATIONS**

**Required Education**

High School/GED.

**Required Experience**

+ 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 sequential thinker.

+ 2+ years of experience conducting comprehensive healthcare fraud investigations; interacting with state, federal and local law enforcement agencies, as necessary.

+ SIU Process/Systems Expertise.

+ MCO Experience.

+ Fraud Investigation Subject Matter Expert (SME).

+ Proficient knowledge and experience in the Fraud, Waste, and Abuse field.

+ Knowledge and experience in Medicaid/Medicare/Marketplace healthcare.

+ Knowledge of healthcare coding, billing and Medicaid/Medicare/Marketplace policy, Federal regulation and/or State laws, rules, and guidelines.

+ Demonstrated proficiency in analyzing the quality and necessity of health care services (inpatient and community based) and communicate results effectively.

+ Proficiency in research, understanding, interpreting and application of government rules/regulations/policies

+ Ability to conduct research, gather information and analyze a variety of data.

+ Strong computer skills required, including working knowledge of the usage of E-mail, MS word and Excel; strong communication skills, both oral and written; prior experience in a leadership role desired.

+ Required License, Certification, Association

+ Healthcare Anti-Fraud Associate (HCAFA), Accredited Health Care Fraud Examiner (AHFI) and/or Certified Fraud Examiner (CFE) preferred.

+ Valid driver’s license required.

To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

Pay Range: $24 - $56.17 / HOURLY

*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.