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Fraud Investigator II

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POST DATE 9/7/2016
END DATE 10/21/2016

Tufts Health Plan Watertown, MA

Watertown, MA
AJE Ref #
Job Classification
Full Time
Job Type
Company Ref #
Mid-Career (2 - 15 years)
Bachelors Degree


The Investigator II serves a key role in addressing inappropriate increases in medical trend due to fraud waste and abuse by investigating provider billing practices and member misrepresentations. Investigations involve extensive internal and external research and detailed data analysis. The Investigator II completes investigations of Tufts Health Plan providers and members to identify fraudulent and abusive billing practices; and member misrepresentations related to eligibility, identity or abuse of benefits. The Investigator II determines root causes, evaluates coding issues and prepares reports and summaries for internal recovery efforts or for referral to state and federal enforcement agencies.

* Conducts claims audits and investigations of THP providers to identify fraud and abusive billing patterns, claim overpayments and miscoding.
* Prepares investigative plans and reports for the Fraud Prevention & Recovery Unit Manager and Director.
* Develops recommendations for inclusion in audit reports that determine root causes and lead to corrective actions.
* Meets with providers, THP clinical specialists, claims operations and other internal departments to discuss and resolve audit findings and makes recommendations for referrals to outside enforcement agencies.
* Conducts other audit fieldwork to assess conduct and intent, and to identify weaknesses in internal controls, contracts or policies.


* Bachelor's degree in Business, Computer Science , Criminal Justice, Clinical or related field.
* Individual possessing professional designation, such as an RN, RPh, or CPA is a plus.


* Four to six years of experience as a health care fraud and abuse investigator.
* Four years claims-related experience preferred, including a strong working knowledge of coding, fee & reimbursement and claims processing policies and procedures.
* Exposure to the health care insurance industry in other audit related positions will be considered.
* Working knowledge of data analysis platforms and medical terminology is necessary; experience reviewing medical records preferred.
* Clinical or Pharmacy expertise is a plus.
* Strong oral and written communications skills required.
* Need experience with SQL-based programs and databases, such as MS Access.
* Specific skills and experience with fraud detection software systems also a plus.
* Experience working with healthcare providers or within a government or private health plan is required.

SKILL REQUIREMENTS: (Include interpersonal skills)

Able to assess complex health care fraud and abuse challenges concerning data, policies and procedures, and make assessments and recommendations after a full, complete and thoughtful investigation, to achieve interventions designed to address inappropriate increases in medical trend and improve systems consistent with the objectives of the organization. Must be able to work cooperatively as a team member within the legal department .

WORKING CONDITIONS AND ADDITIONAL REQUIREMENTS (include special requirements, e.g., lifting, travel, overtime)

Office setting. Open cubicle in a multi-floored office building. Moderate travel within Massachusetts and some (less than 5%) travel out-of-state.

Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled


Founded in 1979 as a non-profit health maintenance organization (HMO), Tufts Health Plan is one the country's largest HMO offering a full array of healthcare coverage options to individual consumers and employer groups. Tufts Health Plan has received high marks for its quality from a variety of third parties including U.S News & World Report and Newsweek.