Senior Fraud Investigator – Health Care

Remote, North Carolina

Who we are:

Constellation Quality Health, formerly CCME, is a non-profit health care quality organization and QIO-like Entity certified by the Centers for Medicare & Medicaid Services (CMS) founded by physicians in 1983. Headquartered in North Carolina’s Research Triangle, we offer an array of quality improvement, clinical review, audit, technical, and consulting services and solutions to improve care delivery, system performance, and patient outcomes.

What you’ll do:

We are seeking a Senior Fraud Investigator to be responsible for conducting and resolving complex health care fraud investigations in support of client fraud, waste, and abuse (FWA) contracts. Investigations include, but not limited to, witness interviews, surveillances, background checks, data analytics to identify outlier billing behavior, contract and program regulation research, provider and member education, provider communication, investigative report writing and closure of investigative cases.

We expect you to:

• Conduct complex health care FWA investigations, including but not limited to witness interviews, surveillances, background checks, data analytics to identify outlier billing behavior, contract and program regulation research, provider and member education, provider communication, investigative report writing and closure of investigative cases.
• Document appropriately all case related information in the case management system in an accurate manner, including storage of case documentation.
• Ensure compliance with applicable contractual requirements, and federal and state regulations.
• Prepare appropriate FWA referrals to regulatory agencies and law enforcement.
• Support arbitrations, legal procedures, and settlements.
• Participate in Business Development activities as requested including RFP/Grant response development, conference attendance, customer identification, and others.
• Operate as a positive member of the investigations, PI, and Program Solutions teams, ensuring a culture of cooperation, mutual support, professionalism, and high reliability.
• Travel within the U.S. required for investigations, customer meetings and conferences.

This position is contingent upon contract award and works remotely. Preference will be given to candidates located in North Carolina.

Who You Are

The Senior Fraud Investigator is an expert in health care fraud investigations with a high attention to detail. The successful candidate must understand current and future trends in health care fraud, waste, and abuse, population health and reimbursement.

Our requirements for this role:

• Bachelor’s Degree required.
• Master’s degree preferred.
• 3+ years of health care or general fraud investigations related experience including SIU or FWA programs.
• Prior law enforcement experience highly preferred (FBI, HHS-OIG, state, or local law enforcement).

Why Constellation Quality Health:

We offer a competitive salary and benefits package and a flexible work environment.

• Equal opportunity employer of protected veterans.
• Equal opportunity employer of individuals with disabilities.
• We do not discriminate on the basis of race, ancestry, color, religion, sex, age, marital status, sexual orientation, gender identity, national origin, medical condition, disability, veteran status, or any other basis protected by law.
• Applicants and employees are protected from discrimination based on inquiring about, disclosing, or discussing compensation or the compensation of other applicants or employees.