Fraud Investigator

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POST DATE 9/11/2016
END DATE 10/11/2016

NCI Information Systems, Inc. Nashville, TN

Nashville, TN
AJE Ref #
Job Classification
Full Time
Job Type
Company Ref #
Entry Level (0 - 2 years)
High School Diploma or GED
Min Salary
Max Salary
Salary Unit
per year


Designated a 2016 Military Friendly® Employer

NCI: As the Fraud Investigator ( Program Integrity Analyst ) at AdvanceMed, you will perform in-depth evaluation of potential fraud investigations and develop investigations that involve monetary losses, sensitive issues, meet criteria for referral to law enforcement, or the imposition of administrative actions. In assuming this position, you will be a critical contributor to meeting NCI's mission: To deliver innovative, cost-effective solutions and services that enable our customers to rapidly adapt to dynamic environments.
Highlights of Responsibilities:
* Conduct independent investigations resulting from the discovery of situations that potentially involve fraud, waste, or abuse.
* Utilize data analysis techniques to detect aberrancies in Medicare claims data, and proactively seek out and develop leads received from a variety of sources (e.g., CMS, OIG, fraud alerts).
* Complete written referrals to law enforcement and takes steps to initiate recoupment of overpaid monies.
* Respond to requests for information from law enforcement.
* Maintain cases that were referred to law enforcement.
* Maintain the 'Do not pursue' list.
* Review information contained in standard claims processing system files (e.g., claims history, provider files) to determine provider billing patterns and to detect potential fraudulent or abusive billing practices or vulnerabilities in Medicare policies and initiates appropriate action.
* Make potential fraud determinations by utilizing a variety of sources such as the ZPIC's internal guidelines, Medicare provider manuals, Medicare regulations, and the Social Security Act.
* Develop and prepare potential Fraud Alerts and Program Vulnerabilities for submission to CMS.
* Share information on current fraud investigations with other Medicare contractors, law enforcement, and other applicable stakeholders.
* Review and respond to requests for information from Medicare stakeholders as assigned.
* Pursue applicable administrative actions during investigation/case development (e.g., payment suspensions, civil monetary penalties, requests for exclusion, etc.).
* Participate in onsite audits in conjunction with investigation development.
* Provide support of cases at hearing/appeal and ALJ level.
* Maintain chain of custody on all documents and follows all confidentiality and security guidelines.
* Compile and maintain various documentation and other reporting requirements.
* Perform other duties as assigned by PI Management that contribute to ZPIC's goals and objectives.
* High School diploma.
* 1 year of experience with program integrity investigation/detection or a related field that demonstrates expertise in reviewing, analyzing/developing information, and making appropriate decisions.
* 25% expected travel.
* Must have and maintain a valid driver's license issued by the state of residence.
Preferred Education and Experience:
* Successful completion of college or technical degree programs related to the position (e.g., criminal justice, statistics, data analysis, etc.).
* Attained the Certified Fraud Examiners (CFE) designation.
* Knowledge of statistics, data analysis techniques, and PC skills.
* Prior experience with fraud detection and investigation within the Medicare program.
* Previous law enforcement experience, especially in the field of investigations.

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It is the policy of NCI to provide equal opportunity in recruiting, hiring, training, and promoting individuals in all job categories without regard to race, color, religion, national origin, gender, age, disability, genetic information, veteran status, sexual orientation, gender identity, or any other protected class or category as may be defined by federal, state, or local laws or regulations. In addition, we affirm that all compensation, benefits, company-sponsored training, educational assistance, social, and recreational programs are administered without regard to race, color, religion, national origin, gender, age, disability, genetic information, veteran status, sexual orientation, or gender identity. It is our firm intent to support equal employment opportunity and affirmative action in keeping with applicable federal, state, and local laws and regulations.
The information above has been designed to indicate the general nature and level of work performed by employees within the classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of employees assigned to this position.