Healthcare Fraud Investigator *Clinical*

Sanford Health Careers With Purpose

Sanford Health is one of the largest and fastest-growing not-for-profit health systems in the United States. We're proud to offer many development and advancement opportunities to our nearly 50,000 members of the Sanford Family who are dedicated to the work of health and healing across our broad footprint.

Facility: GSS National Campus

Location: Sioux Falls, SD

Address: 4800 W 57th St, Sioux Falls, SD 57108, USA

Shift: 8 Hours - Day Shifts

Job Schedule: Full time

Weekly Hours: 40.00

Salary Range: $29.00 - $46.50

Department Details

Bachelor's degree in health related field or equivalent education is required.

Minimum 3 years' experience in health insurance investigation/audit.

Master's Degree preferred.

Accredited Health Care Fraud Investigator (AHFI) certification or Certified Fraud Examiner (CFE) preferred.

Nursing or other clinical experience highly preferred.

Job Summary

Responsible for conducting audits and investigations of potentially fraudulent claim activity. Will plan, develop, and implement investigative processes and procedures. Conduct preliminary investigations, involving internal and external research, detailed data analyses, review of medical records, and interviews of members, providers, and other third parties. Analyzes information gathered by the investigation/audit and report findings, preparing written summaries and recommendations. Conducts investigative interviews of patients and providers as necessary. Prepare evidence package for referral to third parties including contract holders, state insurance fraud bureaus and law enforcement agencies. Respond to subpoenas and requests for information from law enforcement agencies and State Departments of Insurance. May represent company as a witness in judicial proceedings when appropriate. Performs special projects requiring expertise in fraud detection, data analytics, investigation, claim auditing and other areas related to Special Investigations. Completes reports of investigative findings and recommends investigative next steps. Identifies root causes of fraud, proposing internal and external corrective actions to address these root causes. Advises on investigative priorities, strategies, and techniques. Apply laws, regulations, plan policies and guidelines, contract provisions, coding rules, coverage rules, and industry standards to information gathered during the investigation. Share expertise and promoting investigative best practices among management and staff. Educate and collaborate with various business units to raise awareness of potential concerns. Must have excellent communication and interpersonal skills, along with strong analytical and problem-solving abilities. Ability to work on complex projects with general direction and minimal guidance.

Qualifications

Bachelor's degree in health related field or equivalent education is required.

Master's degree is preferred.

Minimum 3 years' experience in health insurance investigation/audit.

Accredited Health Care Fraud Investigator (AHFI) certification or Certified Fraud Examiner (CFE). Or eligible for certification within 1 year.

Benefits

Sanford Health offers an attractive benefits package for qualifying full-time and part-time employees. Depending on eligibility, a variety of benefits include health insurance, dental insurance, vision insurance, life insurance, a 401(k) retirement plan, work/life balance benefits, and a generous time off package to maintain a healthy home-work balance.

Sanford is an EEO/AA Employer M/F/Disability/Vet. If you are an individual with a disability and would like to request an accommodation for help with your online application, please call 1-877-673-0854 or send an email to talent@sanfordhealth.org. Sanford Health has a Drug Free Workplace Policy. An accepted offer will require a drug screen and pre-employment background screening as a condition of employment.