• Fraud, Waste and Abuse Investigator

    Job Locations US-RI-Smithfield
    Req No.
    NHPRI Department
    425 - Compliance
    Regular Full-Time
  • Overview

    Responsible for the intake, review and documentation of Fraud, Waste and Abuse (FWA) allegations referred to the Special Investigations Unit (SIU). Provides recommendations to close inquires or open investigative cases to pursue the prevention, detection, and prosecution of healthcare FWA. Assists in the recovery of funds lost due to FWA and reports cases of suspected fraud to the Office of Program Integrity. Manages regulatory notices (HPMS memos), case summaries and coordinates with external entities, including but not limited to federal, state and law enforcement. Works both independently and collaboratively with the SIU, and other Business Areas to ensure the proper oversight of Neighborhood’s FWA program and assists in identifying areas of non-compliance within the organization. Assists in the preparation of internal and external FWA reporting.


    • Respond to all allegations of potential FWA. Conduct the investigation of fraudulent, wasteful and abusive activities involving members and providers
    • Analyze enrollment data, contract terms, financial records, provider and subscriber claims history, and other documentation to determine FWA and identify potential patterns. Apply regulatory and contractual requirements as well as internal policies and procedures to the case investigation process
    • Perform data analysis, research and review of claims data to identify trends, patterns, outliers and emerging issues in healthcare fraud, waste and abuse with fraud technology
    • Conduct investigations and interviews to gather additional evidence
    • Research and investigate member Identity Theft cases through Member Service referrals
    • Investigate the potential of compromised member information as it relates to security breaches
    • Communicate with members and providers routinely regarding issues including investigative findings, recoveries, and educational feedback where appropriate
    • Compile, report and present case information to Medicaid Fraud Control Unit on a quarterly basis
    • Maintain the integrity of documentation for FWA cases. Update tracking system to ensure documentation of all calls, evidence, referrals, inquiries and case events are accurate for record keeping purposes and for “Discovery” in court related cases
    • Establish and maintain strong relationships with external agencies including the Department of Health, Office of Inspector General, Federal Drug Enforcement, OPI, EOHHS, RI Attorney General, US Attorney and state/local law enforcement
    • Prepare data requests from external law enforcement agencies listed above as required
    • Write clear and concise reports, present findings to providers and participate in negotiated resolution of issues at the direction of management. Track and report any claim adjustments, settlement agreements or payment plan agreements determined as result of investigation or court ordered restitution
    • Use findings to determine where there is a need for a change in policy and course of appropriate action based on line of business, severity of issue, regulatory compliance requirements and plan exposure. Drafts corrective action plan as appropriate    
    • Performs other duties as assigned
    • Corporate Compliance Responsibility - As an essential function, responsible for complying with Neighborhood’s Corporate Compliance Program, Standards of Business Conduct, applicable contracts, laws, rules and regulations, policies, and procedures as it applies to individual job duties, the department, and  the Company. This position must exercise due diligence to prevent, detect, and report unlawful and/or unethical conduct by fellow co-workers, professional affiliates and/or agents



    • Bachelor’s degree in Health Information Management, Health Care Administration, Finance, Criminal Justice, Law Enforcement or related field   
    • At least one (1) year experience working in a Managed Care Organization.
    • Minimum of two (2) years’ experience working on Healthcare Fraud Investigations
    • Proven investigatory skill; ability to organize, analyze, and effectively determine risk with corresponding solutions; ability to remain objective and separate facts from opinions
    • Knowledge of investigative and law enforcement procedures with emphasis on fraud investigations
    • Knowledge of Managed Care and the Medicaid and Medicare programs
    • Understanding of claim billing codes, medical terminology, anatomy and health care delivery systems
    • Understanding of data processing and electronic fraud detection systems
    • Proven ability to research and interpret regulatory requirements
    • Effective interpersonal skills and customer service focus; ability to interact with individuals at all levels
    • Excellent oral and written communication skills; presentation skills with ability to create and deliver training, informational and other types of programs
    • Advanced skills in Microsoft Office (Word, Excel, PowerPoint, Outlook), SharePoint and Intra/Internet as well as proficiency with incorporating/merging documents from various applications
    • Strong logical, analytical, critical thinking and problem-solving skills
    • Initiative, excellent follow-through, persistence in locating and securing needed information
    • Fundamental understanding of audits and corrective actions
    • Ability to multi-task and operate effectively across geographic and functional boundaries
    • Detail-oriented, self-motivated, able to meet tight deadlines
    • Ability to develop realistic, motivating goals and objectives, track progress and adapt to changing priorities
    • Energetic and forward thinking with high ethical standards and a professional image
    • Collaborative and team-oriented


    • Experience investigating Medicaid and Medicare FWA
    • Experience conducting data mining in the healthcare insurance industry and claims related experience
    • National Health Care Anti-Fraud Association certification (AHFI), Certified Fraud Examiner (CFE) or America’s Health Insurance Plans Health Care Anti-Fraud Associate (HCAFA) designation.

    Core Company-Wide Competencies:

    • Communicate Effectively
    • Respect Others & Value Diversity
    • Analyze Issues & Solve Problems
    • Drive for Customer Success
    • Manage Performance, Productivity & Results
    • Develop Flexibility & Achieve Change

    Job Specific Competencies:

    • Build Relationships & Cultivate Networks
    • Attend to Detail & Improve Quality
    • Plan & Organize
    • Exercise Sound Judgement & Decision Making

    Flexible Work Arrangement:

    • Yes

    Telecommuting Arrangement:

    • Yes, up to 2 days a week

    Travel Expectations:

    • Some travel locally between locations may be required

    Neighborhood is an Affirmative Action and Equal Opportunity Employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sexual orientation, national origin, genetic information, age, disability, veteran status or any other legally protected basis.


    Neighborhood is committed to ensuring individuals with disabilities and/or those who have special needs participate in the workforce and are afforded equal opportunity to apply for jobs. If you would like to contact us regarding the accessibility of our Website or need assistance completing the application process, please contact us at recruiting@nhpri.org


    Neighborhood is an EOE M/F/D/V and an E-Verify Employer


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