SIU Fraud Investigator
Mass General Brigham
Summary
The role will be responsible for creating, refining, and performing various analytic reporting aimed at identifying potential fraudulent, wasteful, or abusive claim submissions. In addition to performing analytics, the Data Analyst will be required to conduct preliminary research of identified providers or members, including public records, contracts, and social media reviews. The analyst will be accountable for documenting analytical and research activities in concise reports or memoranda.
Job description
Essential Functions
- Responsible for conducting confidential investigations of suspected fraud, waste & abuse (FWA) involving medical providers, plan members, or other entities or individuals.
- Investigative activities include, but are not limited to: data analysis, public records research, document review, and interviewing.
- Performs case research to include the review, interpretation, and application of payment policies, medical policies, provider manuals, benefits documents, national or local coverage determinations, and other applicable clinical practice parameters, regulations, or guidance pertaining to the submission of claims to health insurance plans.
- Obtains investigative evidence by requesting medical and administrative documents and by conducting interviews of providers, members, or other associated parties.
- Analyzes and interprets multiple sources of data, including health insurance claims, financial transaction information, contract configurations, and other materials.
- Is an expert report writer with the ability to create timely documentation, including investigative plans, case summaries, and interview reports.
- Stays up to date with industry trends, including those pertaining to prevailing fraud, waste & abuse schemes.
Qualifications
Education: Bachelor's Degree Related Field of Study required; experience can be considered in lieu of a degree.
Experience: At least 5-7 years of experience conducting fraud, waste, and abuse investigations required.
Knowledge, Skills, and Abilities
- Strong, demonstrated track record of the ability to execute on time, on budget, and on scope.
- Strong aptitude for technology-based solutions.
- Excellent leadership skills and leadership track record.
- Ability to translate and communicate complex topics in a variety of forums.
- Excellent interpersonal skills.
Working Conditions
This is a hybrid role that requires an on-site presence at the office in Assembly Row, Somerville roughly once per month. This is a full-time role with a Monday through Friday schedule, generally 8:30-5:00 PM Eastern Time. Remote workspace requirements, including privacy and security standards, may be verified in accordance with organizational policy.
Requirements
- Bachelor's Degree in a related field of study required; experience can be considered in lieu of a degree
- At least 5-7 years of experience conducting fraud, waste, and abuse investigations required
- Strong, demonstrated track record of the ability to execute on time, on budget, and on scope
- Strong aptitude for technology-based solutions
- Excellent leadership skills and leadership track record
- Ability to translate and communicate complex topics in a variety of forums
- Excellent interpersonal skills
Benefits
- Flexible work options
- Career growth opportunities
- Competitive salaries
- Comprehensive benefits
- Differentials, premiums and bonuses
- Recognition programs
Company overview
Mass General Brigham is one of the largest integrated healthcare delivery systems in the United States, formed through the merger of Massachusetts General Hospital and Brigham and Women's Hospital. Based in Boston, Massachusetts, this academic medical center system operates multiple hospitals, specialty facilities, and community health centers throughout New England. The organization is renowned for its world-class patient care, cutting-edge medical research, and comprehensive medical education programs. As a teaching affiliate of Harvard Medical School, Mass General Brigham trains the next generation of healthcare professionals while advancing medical science through groundbreaking research initiatives. The system provides a full continuum of healthcare services, from primary care and preventive medicine to complex specialty treatments and emergency services. With a focus on innovation and patient-centered care, Mass General Brigham consistently ranks among the top hospital systems in the nation for clinical excellence and research output.