Background investigator jobs near me - 43 jobs

PRODIGY INVESTIGATIONS OFFERS TOP PAY FOR SUPERIOR RESULTS! We are seeking experienced Background Investigator candidates throughout the country. This is a remote position. Over the past 43 years, Prodigy Investigations has saved employers and insurance carriers 100's of Millions of Dollars. More than 50,000 employers have trusted Prodigy Investigations to solve big problems fast, close claims quicker, and save more money. Prodigy Investigations is the best choice to refute fraudulent claims. Job duties include, but are not limited to: setup new surveillance cases in database, conduct pre-surveillance research, research locations, backgrounds, and social media profiles, assistance with claims investigations, locates, online investigations, court research, and report writing. This is a fun, dynamic, and exciting career! Every day is unpredictable. Job Duties include: Internet research Social media investigations Locates Vehicle identification Asset Investigations Pre Surveillance Planning Develop address histories New surveillance investigations intake Data entry Driving records License plate searches Pre-employment background checks Court research & public records requests Freedom of Information Act requests Report writing Open Source Intelligence (OSINT)

Background Investigator - Independent Contractor/1099 Federal Background Investigations Division 1FORCE is currently seeking to engage with experienced Contractors and federally credentialed Background Investigators to conduct personnel security background investigations in a contractor capacity in support of our client's contracts with the federal government. We have work nationwide and if you currently hold credentials on a federal personnel security background investigations contract (or have held government credentials in the last 2 years), we want to partner to provide immediate, weekly work opportunities. DUTIES & RESPONSIBILITIES: Complete record searches. Conduct face-to-face interviews to elicit information about applicants seeking federal positions, contract positions or positions within the military. Obtain factual information from a variety of personal and record sources to produce a report of investigation, containing all pertinent facts, of an individual's background and character, in accordance with agency guidelines and instructions. Investigators work from home, set their own schedules, and work independently. Self-motivated, highly independent, and prepared to work non-traditional hours (i.e., evenings and weekends). POSITION REQUIREMENTS: Federally credentialed and experienced investigators will have met the background investigations national training standards and have 12 months or more of consecutive experience performing executive branch investigations. Superior organizational and time management skills. Excellent communication skills in both oral and written formats. Strong computer and typing skills for composing narrative reports of investigation in FWS and utilizing PIPS or other federally supported case management/reporting system. Sufficient E&O liability, car insurance and personal insurance. **All candidates must be a US Citizen and be able to obtain a TOP SECRET level security clearance.

The Clinical Investigator monitors service delivery for program integrity through fraud and abuse investigations and audits, including review of claims data, clinical records and reference materials, investigative interviewing, provider education and technical assistance, and monitoring implementation of provider corrective actions. The Investigator reports overpayments and other irregularities and confers with Special Investigations Unit, Senior Management, Chief Compliance Officer and General Counsel as needed. This position will allow the successful candidate to work primarily remote schedule. The candidate must be a resident of North Carolina or reside within 40 miles radius of North Carolina's border. There is no expectation of being in the office routinely, however, the selected candidate will be required to travel to provider sites to conduct audits/investigations in Charlotte, North Carolina up to 3 times per month. Responsibilities & Duties Conduct Audit/Investigations and prepare reports Review allegation(s), conduct preliminary investigation and make disposition recommendations using independent judgment Develop audit/investigation plans and tools based upon alleged non-compliance and data analytics Request and/or collect medical records, personnel records, policies/procedures, compliance plans, and other documents from providers based on audit/investigation plans Systematically and accurately collect, document, and store evidence Conduct post-payment audits of Medicaid and State funded providers to ensure that services are rendered in accordance with established state and federal rules, regulations, policies, and terms of provider contractual agreements with the state Identify inappropriate billing and overpayments Utilize clinical knowledge and experience to determine if documented services were clinically appropriate and/or medically necessary Conduct interviews with provider employees, former employees, recipients of services, and other witnesses Document allegations, investigative activities, and findings in a detailed audit/investigation report Work with the Special Investigations Supervisor and Investigative Team to support investigative activities Assure that individuals served do not pay for health services inappropriately Track allegations of fraud, waste, and abuse in a case management system from referral to final disposition Consult with the Corporate Compliance Unit when potential internal compliance issues are identified Consult on cases Provide clinical guidance to non-clinical staff on documentation obtained from providers Provide guidance to non-clinical staff on Medicaid Clinical Coverage Policies and State Service Definitions and by participating in ad hoc meetings related to clinical regulatory matters Participate in ad hoc meetings related to clinical matters Conduct Regulatory Review/ Research Diligently research clinical policies, administrative code, federal/state laws in order to assess for non-compliance Analyze data Analyze data from a variety of sources, including but not limited to claims, authorizations, credentialing/enrollment, grievances, prior audits/investigations, incarceration records, incident reports, policies/procedures, to inform decision making Utilize various MicroStrategy reports data during the investigation process Analyze claims data to determine if an allegation is supported Analyze claims data during investigations to determine if there are indicators of fraud/abuse other than the allegation received Identify other data sources to review during investigations based on the allegation(s) Provide Case reports/presentations to internal and external stakeholders Present audit/investigation findings and make disposition recommendations using independent judgment to the Chief Compliance and Risk Officer, Senior Director of Program Integrity, Special Investigations Supervisor, and Alliance Compliance Committee Present case status updates in individual supervision sessions, unit team meetings, Division meetings (as designated by supervisor), and to NC Department of Justice (as requested) Conduct and participate in Investigation Planning meetings with the Investigation Team Interpret and convey highly technical information to others Provide Technical Assistance/Education Educate providers on the errors identified in the audit and investigation process Recognize when providers can improve through technical assistance (TA) rather than full investigation when FWA is not evident and/or pervasive Recognize quality of care issues in order to make recommendations to appropriate entities/authorities Monitor Provider Action and Follow-Up Document Improper Payment Charts, Statements of Deficiency, provides feedback and technical assistance to providers as needed/requested, and follows up on provider corrective action through the probation process, as applicable Prepare for and participate in provider appeal process and/or court hearings to explain and defend audit/investigation findings Recommend policy, procedure, or process changes Recommends revisions to Alliance Health procedures and policies Minimum Requirements Education & Experience Graduation from an accredited school of Nursing with a Registered Nurse (RN) license and five (5) years relevant post-graduate experience. OR Master's degree in human services/social sciences, health care compliance, analytics, government/public administration, auditing, security management, criminal justice, or pre-law and Five (5) years relevant post-graduate experience. Special Requirement- Current, unencumbered clinical license as an LCSW, LCMHC, LMFT, LCAS, LPA or RN Preferred Health care industry and/or Medicare/Medicaid/Behavioral Health experience and knowledge SIU and/or regulatory compliance work experience National Certified Investigator and Inspector Training (NCIT) Basic and Specialized Knowledge, Skills, & Abilities Knowledge of Health care industry and/or Medicare/Medicaid/Behavioral Health Knowledge of the state and federal Medicaid laws, state and federal criminal and civil fraud laws, regulations, policies, rules, guidelines, service limitations, and various Medicaid programs Knowledge and proficiency in claims adjudication standards & procedures Knowledge of investigative methods and procedures High degree of integrity and confidentiality required handling information that is considered personal and confidential Skill in using Microsoft Office products (such as Word, Excel, Outlook, etc.) Analytical skills and ability to make deductions; logical and sequential thinker Strong verbal and written communication skills. Ability to write clear, accurate and concise rationale in support of findings Ability to manage time, prioritize work, and use problem-solving approaches Ability to interpret contractual agreements, business-oriented statistics medical/administrative services and records Ability to identify resources, gather evidence, analyze raw data and generate reports A general understanding of all major managed care functions in particular as it relates to prior authorization, utilization reviews, grievance management, provider credentialing and monitoring Knowledge of the Alliance Health service benefit plans and network providers Employment for this position is contingent upon a satisfactory background and MVR (Motor Vehicle Registration) check, which will be performed after acceptance of an offer of employment and prior to the employee's start date. Salary Range $77,868 - $99,282/Annually Exact compensation will be determined based on the candidate's education, experience, external market data and consideration of internal equity An excellent fringe benefit package accompanies the salary, which includes: Medical, Dental, Vision, Life, Long Term Disability Generous retirement savings plan Flexible work schedules including hybrid/remote options Paid time off including vacation, sick leave, holiday, management leave Dress flexibility

Care Access is working to make the future of health better for all. With hundreds of research locations, mobile clinics, and clinicians across the globe, we bring world-class research and health services directly to communities that often face barriers to care. We are dedicated to ensuring that every person has the opportunity to understand their health, access the care they need, and contribute to the medical breakthroughs of tomorrow. With programs like Future of Medicine , which makes advanced health screenings and research opportunities accessible to communities worldwide, and Difference Makers , which supports local leaders to expand their community health and wellbeing efforts, we put people at the heart of medical progress. Through partnerships, technology, and perseverance, we are reimagining how clinical research and health services reach the world. Together, we are building a future of health that is better and more accessible for all. To learn more about Care Access, visit ******************* How This Role Makes a Difference The Sub-Investigator will be responsible for travel mixed with remote tele-medicine work to support our clinical research studies. Additionally, our Sub-Investigator will be skilled in administering investigational products (IV, SC, TD, IM, PO administration), performing physical examinations, monitoring for investigational product related reactions, among other duties beyond the standard clinical research Sub-Investigator role. Care Access is looking for highly motivated Nurse Practitioners or Physician's Assistants to support clinical trial related activities in states throughout the USA. How You'll Make An Impact Work closely with the Principal Investigator to oversee the execution of study protocols, delegating study related duties to site staff, as appropriate, and ensuring site compliance with study protocols, study-specific laboratory procedures, standards of Good Clinical Practice (GCP), Standard Operating Procedures (SOPs), quality (QA/QC) procedures, OSHA guidelines, and other state and local regulations as applicable. Attends and participates in meetings with the director, other managers, and staff as necessary. Complies with regulatory requirements, policies, procedures, and standards of practice. Read and understand the informed consent form, protocol, and investigator's brochure. Be available to see subjects virtually or in-person as dictated by project design, answer their questions, and resolve medical issues during the study visit. Sign and ensure that the study documentation for each study visit is completed. Perform all study responsibilities in compliance with the IRB approved protocol. Administration of Investigational Products (via subcutaneous, transdermal, intramuscular, intravenous, or oral routes). Proficiency in starting, monitoring, and maintaining intravenous lines. Proficiency in phlebotomy, proper blood collection practices, and laboratory processing practices (can be learned) Contribute as an active member of clinician team involved in the management of infusion or other investigational product related reactions. Maintain a clean, efficient clinical area to assure the highest standards of patient care. Follow safety and PPE procedures as well as maintain proper documentation of infusion procedures. Timely communications with internal teams, investigators, review boards, and study subjects Perform trial procedures as per delegation which can include the following but not limited to: Prescreen study candidates by telephone and review exclusionary conditions or medications prior to scheduling screening appointment. Obtain informed consent per SOP. Administer delegated study questionnaires, as appropriate. Collect and evaluate medical records. Complete visit procedures and ensure proper specimen collection, processing, and shipment in accordance with protocol. Train others and complete basic clinical procedures, such as blood draws, vital signs, ECGs, etc. Review screening documentation and approves subjects for admission to study. Review admission documentation and approves subject for randomization. Provide ongoing assessment of the study subject/patient to identify Adverse Events. Ensure that serious and unexpected adverse events are reported promptly to the Pl. Review and evaluates all study data and comments to the clinical significance of any out-of-range results. Perform physical examinations as part of screening evaluation and active study conduct. Provide medical management of adverse events as appropriate. Dispense study medication per protocol and/or IVRS systems. Educate patient on proper administration and importance of compliance. Monitor patient progress on study medication. Other duties as assigned. The Expertise Required Ability to check, perform, and document vitals as well as EKG (ECG) Phlebotomy and expert IV skills Excellent working knowledge of medical and research terminology Excellent working knowledge of federal regulations, good clinical practices (GCP) Ability to communicate and work effectively with a diverse team of professionals. Strong organizational skills: Able to prioritize, support, and follow through on assignments with good understanding of medical terminology. Communication Skills: Strong verbal and written communication skills as evidenced by positive interactions with coworkers, management, clients and vendors. Communication Skills: Strong verbal and written communication skills as evidenced by positive interactions with coworkers, management, clients and vendors. Team Collaboration Skills: Work effectively and collaboratively with other team members to accomplish mutual goals. Bring positive and supportive attitude to achieving these goals. Strong computer skills with demonstrated abilities using clinical trials database, IVR systems, electronic data capture, MS word and excel. Ability to balance tasks with competing priorities. Critical thinker and problem solver. Curiosity and passion to learn, innovative, and able to take thoughtful risks while communicating concerns and mitigations. Good management and organizational skills, understanding of medical procedures. Exceptional interpersonal skills, willingness to the ability to work independently. Ability to lift a minimum of 50 pounds. Command of professional and Business English (written and spoken). You must have the authorization to work in the US for any employer. You must not need visa sponsorship, either now or in the future. You must live in the USA and be willing and able to travel with 24-36-hour notice Certifications/Licenses, Education, and Experience: At least Master's Level Science Degree. Nurse Practitioner or Physician Assistant with 5+ years of clinical experience. Clinical practice experience desired with infusion skillset. Currently licensed in good standing in one or more states. A minimum of 1 year of relevant work experience as Sub-Investigator (preferred) in a Clinical Research setting. Preferred at least one (1) year of experience as a Clinical Research Coordinator or willingness to learn. How We Work Together Location: Remote within the United States. This is an on-site mixed with remote tele-medicine work position. Travel: Regional and nationwide travel requirements up to 100% dependent on project design and business need. Regularly planned travel will be required as part of the role. Physical demands associated with this position Include: The ability to use keyboards and other computer equipment. The expected salary range for this role is $130,000 - $165,000 USD per year for full time team members. Benefits & Perks (US Full Time Employees) Paid Time Off (PTO) and Company Paid Holidays 100% Employer paid medical, dental, and vision insurance plan options Health Savings Account and Flexible Spending Accounts Bi-weekly HSA employer contribution Company paid Short-Term Disability and Long-Term Disability 401(k) Retirement Plan, with Company Match Diversity & Inclusion We work with and serve people from diverse cultures and communities around the world. We are stronger and better when we build a team representing the communities we support. We maintain an inclusive culture where people from a broad range of backgrounds feel valued and respected as they contribute to our mission. We are an equal opportunity employer, and all qualified applicants will receive consideration for employment without regard to, and will not be discriminated against on the basis of, race, color, religion, sex, sexual orientation, gender identity or expression, pregnancy, age, national origin, disability status, genetic information, protected veteran status, or any other characteristic protected by law. Care Access is unable to sponsor work visas at this time. If you need an accommodation to apply for a role with Care Access, please reach out to: ********************************

Hybrid: This role requires associates to be in-office 1 - 2 days per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of virtual work, promoting a dynamic and adaptable workplace. Alternate locations may be considered if candidates reside within a commuting distance from an office. Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law. Carelon Payment Integrity is a proud member of the Elevance Health family of companies, Carelon Insights, formerly Payment Integrity, is determined to recover, eliminate and prevent unnecessary medical-expense spending. The Investigator II is responsible for the identification, investigation and development of cases against perpetrators of healthcare fraud in order to recover corporate and client funds paid on fraudulent claims. How you will make an impact: * Claim reviews for appropriate coding, data mining, entity review, law enforcement referral, and use of proprietary data and claim systems for review of facility, professional and pharmacy claims. * Responsible for identifying and developing enterprise-wide specific healthcare investigations that may impact more than one company health plan, line of business and/or state. * Effectively establish rapport and on-going working relationship with law enforcement. * May interface internally with Senior level management and legal department throughout investigative process. * May assist in training of internal and external entities. * Assists in the development of policy and/or procedures to prevent loss of company assets. Minimum Requirements: * Requires a BA/BS and minimum of 3 years related experience; or any combination of education and experience, which would provide an equivalent background. Preferred Skills, Capabilities and Experiences: * Fraud certification from CFE, AHFI, AAPC or coding certificates preferred. * Knowledge of Plan policies and procedures in all facets of benefit programs management with heavy emphasis in negotiation preferred. * Health insurance, law enforcement experience preferred. For candidates working in person or virtually in the below locations, the salary* range for this specific position is $69,440 to $104,160. Location: Columbus, OH In addition to your salary, Elevance Health offers benefits such as a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the Company. The Company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws. * The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education, and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations. No amount is wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company's sole discretion, consistent with the law. Job Level: Non-Management Exempt Workshift: Job Family: FRD > Investigation Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health. Who We Are Elevance Health is a health company dedicated to improving lives and communities - and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve. How We Work At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business. We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few. Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process. The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws. Elevance Health is an Equal Employment Opportunity employer, and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact ******************************************** for assistance. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.

OMNIPLEX World Services Corporation is seeking talented individuals committed to excellence, honesty, and integrity to join our team. We are a trusted provider of high quality background investigations programs to Department of Homeland Security (DHS) and the intelligence community at locations throughout the United States. OMNIPLEX is seeking to fill immediate and upcoming openings for Contract Investigators. A Contract Investigator works for us on an as needed basis and no hours are guaranteed. We prefer Contractors to be available to work a minimum of ten hours per week where work is available. Candidate must be willing to travel within a 35-50 mile radius from city location. Candidate must be local to Columbus, OH QUALIFICATIONS: U.S. Citizenship; H.S. Diploma or equivalent; Minimum of 1 year of specialized Federal Background investigative experience within the last 5 years; Must have some FIS Experience; Reliable personal vehicle, valid driver's license, and satisfactory driving record; Willing to travel on temporary duty assignments as needed (by car or plane); Successfully pass background checks and all required training; Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists; Ability to interpret a variety of instructions furnished in oral, written, diagram, or schedule form; Ability to read, analyze, and interpret professional journals, technical procedures, or governmental regulations; Ability to write reports and business correspondence; Ability to work in a MS Window based operating environment, including proficiency with Microsoft Office (Word, Excel, PowerPoint), Internet and E-mail; Current (within the last 2 years) Single Scope Background Investigation (SSBI) or active Secret level security clearance based on an SSBI and able to obtain the required security clearance. Job Duties and Responsibilities: Conduct in-person, one-on-one subject interviews to obtain factual information about the individual's background and character, in accordance with agency guidelines and instructions. Obtain factual information from a variety of personal and record sources to produce a report of investigation that contains all pertinent facts of an individual's background and character in accordance with agency guidelines and instructions. Travel throughout the geographic area of responsibility to conduct investigations at various places of employment, residence, and education institutions as cases are assigned. Must be willing to travel in and around assigned location within 30-50 miles (or more) as needed Engage in dialogue on a regular basis with managers and representatives at contractor facilities, various U. S. Government organizations, and law enforcement agencies to develop and maintain effective and cooperative working relationships. Adapt to changing situations and environments as they occur and be able to interact with people from all walks of life and socioeconomic levels. Demonstrate strong verbal and written communications skills and exhibit professional demeanor in all situations. Work load based on availability of cases in geographic area. Some voluntary, temporary duty assignments in other areas of the country (typically 2-4 weeks at a time) are possible. Other duties as required. Desired Experience and Education: Background Investigator Training that meets the National Training Standards (NTS) Prior background investigations experience supporting government contracts. Associate or Bachelor degree in Criminal Justice or a related field. Current Top Secret clearance WORKING CONDITIONS: Work is typically based in the investigator's home office as well as in the investigator's personal vehicle traveling to various field locations to conduct interviews. Coverage area varies and could include some extended drives. Work hours vary depending on availability of leads and do not always fall within normal business hours, to include potential weekend hours or third-shift appointments. PHYSICAL REQUIREMENTS: Requires intermittent standing, writing/typing, walking, sitting, and driving throughout the workday, and may include for multiple hours.

Job Description ABOUT US: Ethos Risk Services is a leading insurance claims investigation and medical management company, specializing in surveillance and fraud detection. At the forefront of, we provide accurate data and actionable insights that translate into better decision-making for our clients. To learn more, visit: ******************************* JOB SUMMARY: Have you ever thought about becoming a Private Investigator? Are you ready to kick-start your career in a rapidly growing industry? Want to get paid to learn how to investigate fraud and conduct covert surveillance in the real world? Our Full-Time Entry-Level Field Investigator position will help launch your career by providing you with an industry leading FULLY PAID Investigator Training Program - no prior experience necessary! KEY RESPONSIBILITIES: Case Preparation: Conduct preliminary investigations using social media and analyzing database research. Field Surveillance: Perform covert surveillance from your vehicle by tracking and capturing high-quality video evidence of surveillance targets. Report Writing: Draft detailed and court-ready investigative reports summarizing activity and key findings. Documentation: Finalize case files by submitting case reports and uploading video footage via personal laptop at the end of the day. Communication: Work closely with field supervisor, receiving regular guidance and mentorship. QUALIFICATIONS: Driver's License: Active driver's license that is not currently suspended or revoked. Personal Vehicle: A well-maintained vehicle that is always reliable (preferably with tinted windows). Proof of auto insurance coverage is required. Travel Expectations: While we aim to keep assignments within a reasonable drive of your residence, occasional further travel and overnight stays (covered by the company) may be required. Technology: A reliable laptop, cell phone, and internet service are needed for communication and administrative tasks. Required Skills: Strong computer & internet proficiency. Excellent communication, verbal & writing skills. WHAT WE OFFER: Paid Investigator Training Program: Fully paid training program led by industry experts with ongoing development and support. Initial training will be held via virtual classroom then transition into on-the-job training. Paid Licensing: We pay for all your licensing fees! Our licensing team will guide you through the process of acquiring all investigator licensing to ensure a smooth process. Surveillance Equipment: We will provide you with necessary surveillance equipment. After a year of employment, it is yours to keep! Pay Increases & Milage Reimbursement: There are several performance milestones within your training & first year of employment that will reward you with pay increases. Additionally, we offer a mileage reimbursement program. Health Insurance/Retirement: Medical, Dental Vision, Life/Disability Insurance + 401k WORKING CONDITIONS: Most surveillance cases start at 6:00AM. End time can vary depending on activity and a typical workday can vary from 3-12 hours. Weekends/holidays are common workdays as claimants are more likely to be active. This is an independent role often requiring long hours alone in your vehicle, regardless of weather conditions. Must remain alert with no external distractions, ready to use videography equipment to document subjects. Ethos Risk Services is an equal opportunity employer that does not discriminate on the basis of religious creed, sex, national origin, race, veteran status, disability, age, marital status, color or sexual orientation or any other characteristic. A background check will be conducted, in accordance to the local state law and regulations. Job Posted by ApplicantPro

Our team members are at the heart of everything we do. At Cencora, we are united in our responsibility to create healthier futures, and every person here is essential to us being able to deliver on that purpose. If you want to make a difference at the center of health, come join our innovative company and help us improve the lives of people and animals everywhere. Apply today! Job Details Summary: Under the general direction of the Director of Diversion Control Program, supports the Diversion Control Program through investigative research and other duties, as assigned. Primary Duties and Responsibilities: Assists in the implementation and operation of the Diversion Control Program Conducts investigative research via the Internet and public record databases Conducts Customer Due Diligence (DD) and Suspicious Order Monitoring (SOM) Investigations Supports the Diversion Control Analyst in the generation of sales reporting as a result of information requests from state and/or federal regulatory authorities Supports the Diversion Control Analyst in updating the monthly parameter and related OMP maintenance Monitors and adjusts customer OMP parameters, according to Diversion Control Program policy, as required Acts as liaison and maintains contact with Sales and Customer Maintenance departments regarding diversion control concerns, as necessary Acts as liaison with distribution center compliance teams Generates statistical data on a monthly basis, as directed Assists with conducting analysis of customer dispensing reports Assists with conducting targeted, on-site pharmacy visits, as assigned Assists with DC pre-audit preparation and interviews with state and federal regulators Conducts internal associate training on the Diversion Control Program to other ABC business units, as assigned Composes comprehensive written reports relative to investigative analysis Documents all work in a timely and organized fashion for future retrieval purposes Works independently, requiring less oversight from management and offering coaching to Investigator I level team members Willingness to travel up to 25% Perform related duties as assigned Minimum Skills and Qualifications: Requires broad training in fields such as criminal justice, business administration, accountancy, sales, marketing, computer sciences or similar vocations generally obtained through completion of a four (4) year bachelor's degree program or equivalent combination of experience and education Normally requires five (5) + years of directly related and progressively responsible experience Excellent organization and administrative skills Excellent computer skills including Microsoft Office and preferably familiarity with SAP Strong written and verbal communication skills Strong research skills Ability to multi-task What Cencora offers We provide compensation, benefits, and resources that enable a highly inclusive culture and support our team members' ability to live with purpose every day. In addition to traditional offerings like medical, dental, and vision care, we also provide a comprehensive suite of benefits that focus on the physical, emotional, financial, and social aspects of wellness. This encompasses support for working families, which may include backup dependent care, adoption assistance, infertility coverage, family building support, behavioral health solutions, paid parental leave, and paid caregiver leave. To encourage your personal growth, we also offer a variety of training programs, professional development resources, and opportunities to participate in mentorship programs, employee resource groups, volunteer activities, and much more. For details, visit ************************************** Full time Salary Range*$74,000 - 105,820 *This Salary Range reflects a National Average for this job. The actual range may vary based on your locale. Ranges in Colorado/California/Washington/New York/Hawaii/Vermont/Minnesota/Massachusetts/Illinois State-specific locations may be up to 10% lower than the minimum salary range, and 12% higher than the maximum salary range. Equal Employment Opportunity Cencora is committed to providing equal employment opportunity without regard to race, color, religion, sex, sexual orientation, gender identity, genetic information, national origin, age, disability, veteran status or membership in any other class protected by federal, state or local law. The company's continued success depends on the full and effective utilization of qualified individuals. Therefore, harassment is prohibited and all matters related to recruiting, training, compensation, benefits, promotions and transfers comply with equal opportunity principles and are non-discriminatory. Cencora is committed to providing reasonable accommodations to individuals with disabilities during the employment process which are consistent with legal requirements. If you wish to request an accommodation while seeking employment, please call ************ or email ****************. We will make accommodation determinations on a request-by-request basis. Messages and emails regarding anything other than accommodations requests will not be returned . Affiliated Companies:Affiliated Companies: AmerisourceBergen Services Corporation

Affirmative Civil Enforcement (ACE) InvestigatorEmployment Type: Full-Time, Experienced Department: Legal Services CGS is seeking an experienced ACE Investigator with extensive knowledge and skills in investigative techniques and fraud detection to provide assistance for a large Federal agency initiative. CGS brings motivated, highly skilled, and creative people together to solve the government's most dynamic problems with cutting-edge technology. To carry out our mission, we are seeking candidates who are excited to contribute to government innovation, appreciate collaboration, and can anticipate the needs of others. Here at CGS, we offer an environment in which our employees feel supported, and we encourage professional growth through various learning opportunities. Skills and attributes for success:- The investigator will generate new investigations, and to continue with ongoing investigation and civil actions involving fraud in areas such as healthcare, contracting, and grants, as well as other fraud and abuse of federal public funds and programs. - Regularly meets with the ACE attorneys and with designated agency personnel for the purpose of generating fraud investigations. - Performs a variety of ancillary investigations-related services in direct support of any assigned fraud- Utilizes electronic databases such as public records, property records, business records, and other government-maintained databases, to identify documents, witnesses and other physical evidence. - Prepares reports on progress of investigations for use by AUSAs and supervisory attorneys. These reports may include significant findings and conclusions, analyses of information located in electronic databases, presentations, recommendations for additional investigative actions and candid assessments of strengths and weaknesses of witnesses, documentary evidence, or other aspects of a case. - Examines books, ledgers, payrolls, cost reports, billing statements, invoices, correspondence, computer data, and other records pertaining to the transactions, events, or allegations under investigation. - Performs sophisticated analyses of large-scale hard-copy and electronic data, such as health care claims data, financial transaction data, accounting records, or bank records to develop investigative leads and to determine their potential relevance to the allegations at issue. - Gathers and analyzes facts including witness statements, timelines, and scientific or technical data for the purpose of advancing investigative objectives. Establishes and verifies relationships between facts and evidence obtained or presented to confirm authenticity of documents, to corroborate witness statements, and to otherwise build proof necessary for successful litigation or settlement. - Develops and analyzes evidence and collects information relating to such evidence, or other legal matters under consideration, from appropriate primary and secondary sources. Performs analysis to clarify the target suspect's or organization's pattern of operations, to identify information relevant to the legal issues involved, and to recommend valuable approaches to the AUSAs or other members of the investigative team. Develops and refines proof required to assist in determining legal responsibility for violations. - Assists ACE AUSAs with in-person and/or telephonic interviews of witnesses, depositions, and sworn witness examinations. - Assists with the preparation and service of subpoenas for documentary materials, interrogatory answers, or witness testimony in connection with ACE investigations. - Develops an understanding of all applicable federal, state, or local laws to the extent necessary to make sound decisions on direction and scope of investigations. Determines proof required to affix responsibility for violations, and devise methods for obtaining, preserving, and presenting evidence to the greatest effect. - Assists with determining the most efficacious methods for planning, scheduling, and conducting investigations, and identifies any resources that may be required. - Performs other related ACE investigator duties as assigned and within scope. - Attends meetings and trainings as may be required and appropriate. Qualifications:- Computer Skills: Applicant shall have the ability to use MS Word, MS Excel, MS Outlook, MS Access, and other databases as well as Adobe Acrobat Professional. Experience with working on document review/management platforms such as Relativity, with analyzing spreadsheets of claims data, and with utilizing docketing software is a plus. - Ability to review and understand the import of a wide variety of documents, both legal and non-legal, including Motions and Briefs. - Ability to think independently and to develop investigative strategies in response to the needs of a specific case. - Communication skills are extremely important. Applicant shall work and interact professionally and effectively with all levels of staff. - Ability to meet established deadlines and work as a team player in a professional office. - Skill in meeting and dealing with people in a courteous and tactful manner. Our Commitment:Contact Government Services (CGS) strives to simplify and enhance government bureaucracy through the optimization of human, technical, and financial resources. We combine cutting-edge technology with world-class personnel to deliver customized solutions that fit our client's specific needs. We are committed to solving the most challenging and dynamic problems. For the past seven years, we've been growing our government-contracting portfolio, and along the way, we've created valuable partnerships by demonstrating a commitment to honesty, professionalism, and quality work. Here at CGS we value honesty through hard work and self-awareness, professionalism in all we do, and to deliver the best quality to our consumers mending those relations for years to come. We care about our employees. Therefore, we offer a comprehensive benefits package. - Health, Dental, and Vision- Life Insurance- 401k- Flexible Spending Account (Health, Dependent Care, and Commuter)- Paid Time Off and Observance of State/Federal Holidays Contact Government Services, LLC is an Equal Opportunity Employer. Applicants will be considered without regard to their race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran. Join our team and become part of government innovation! Explore additional job opportunities with CGS on our Job Board:******************* com/join-our-team/For more information about CGS please visit: ************ cgsfederal. com or contact:Email: info@cgsfederal. com #CJ

Our Company At AssuranceAmerica, we are more than a unique blend of insurance assets. We believe in creating a culture where every associate has the opportunity to learn and grow. We strive to create a work environment to meet associate needs and we are determined to achieve excellence in everything we do. This is an opportunity to join a dynamic team in a company that is a leader in the non-standard auto insurance space and functions with a small company, entrepreneurial style. This position will require someone with an understanding that one needs to have a “roll up your sleeves” attitude to help make things happen. Job Summary The SIU Investigator is responsible for conducting thorough investigations throughout the 10 states in which we conduct business. The Investigator is responsible for analytical review of suspicious claims utilizing various investigative methods and techniques. The investigator must evaluate relevant information essential in resolving suspicious and complex investigations. This position requires demonstrated effectiveness in the understanding and application of legal and claim principles. The SIU Investigator works under minimal supervision outside the office and would have access to transportation. Only candidates located in the Miami area will be considered. This is a field position and bilingual Spanish is highly preferred. Please note a company car provided. Job Responsibilities Supports Claims Department operations in the research and investigation of suspicious or questionable property damage and injury claims Conducts recorded statements and Examinations Under Oath as required Completes field work as required. Documents claim files and communicates in writing as required Provides office training to ensure recognition of potentially suspicious or fraudulent files in the branch Reports suspicious claims to the department of insurance as required by statute Must ensure compliance with industry and company policies Must understand regulatory / statutory requirements; develops and maintains knowledge of changes in law both at state and national levels Properly utilizes our claims and other various systems Attends industry meetings for communication trends Completes individual monthly Investigator report to manager Attends and participates in team meetings Participates in roundtable meetings Actively affiliates and maintains network of SIU, claims, law enforcement, attorney and related contacts to ensure investigation methods are current and proper operating procedures are utilized Responsible for meeting individual goals and objectives Maintains consistent, fair and diplomatic interactions with co-workers Performs other duties as assigned by SIU Manager Job Qualifications Formal Education & Certification Undergraduate College Degree or equivalent work experience will be considered. Knowledge & Experience 5 years of special investigation experience required. Casualty and PIP claims, as well as medical clinic investigations will be highly preferred. Claims and Property Damage investigations experience will be required. Skills & Competencies Must be able to work in a fast-paced, paperless/automated production environment. Excellent PC skills are required. Excellent communication/interpersonal skills and ability to work with all levels within the organization and deal tactfully and diplomatically with public and outside authorities. Must be able to work as a team player throughout the company. Ensures that the highest degree of professionalism and integrity is maintained, and that decisions are made within the scope of what is fair, reasonable and appropriate according to applicable law and industry standards. Must have the ability to travel when necessary. Bilingual preferred. Florida Adjuster's license is required prior to employment start date.

Job DescriptionDescriptionHealthcare Fraud Shield, a leader in healthcare fraud prevention and payment integrity solutions, is looking for a talented Coder or Clinical Coder/Fraud Investigator to join our team. Key Responsibilities Work with SIU Team (Clinical Reviewers, CPCs, Investigators, Analysts-including performing quality check on work, assisting in research, discuss to make appropriate coding determinations as needed) Analyze and interpret patient medical records (behavioral related and other specialties) pertaining to FWA investigations as needed Compare to information submitted on the claims in order to determine amount and nature of billable services as needed Determines appropriateness of billing and reimbursement as needed Documents findings for each claim line in a spreadsheet as needed Summarize findings in a written report as needed Abstracts CPT, HCPCS, Revenue Codes, DRG codes, and ICD-9/ICD-10 from medical records as needed Responsible for maintaining current knowledge of coding guidelines and relevant federal and/or state regulations as needed Perform data analysis and lead generation/data mining of client data as needed Conduct various aspects of FWA investigations as needed Provide Subject Matter Expertise and SIU support to clients as needed Comply with Privacy and Security standards Understands and complies with all company Privacy and Security standards Employee may not use or disclose any protected health information, except as otherwise permitted, or required, by law Other duties as needed Skills, Knowledge and Expertise Knowledge of medical terminology Knowledge of coding including CPT, HCPCS, Revenue Codes, DRG Codes, and ICD-10 Knowledge of specialty medical practices Must be detail oriented Ability to communicate effectively both verbally and in writing Strong listening skills Independent Responsible Self-disciplined Ability to meet defined performance and production goals Strong computer skills This job requires access to confidential and sensitive information, requiring ongoing discretion and secure information management CERTIFICATE/LICENSE Certified Professional Coder - (CPC ) through governing body AAPC or equivalent certification Minimum of one year of coding and/or billing experience is required. Benefits Medical, Dental & Vision insurance 401(k) retirement savings with employer match Vacation and sick paid time off 7 paid holidays & 2 floating holidays Paid maternity/paternity leave Disability & Life insurance Flexible Spending Account (FSA) Employee Assistance Program (EAP) Professional and career development initiatives Remote work eligible REMOTE WORK REQUIREMENTS Must have high speed Internet (satellite is not allowed for this role) with a minimum speed of 25mbs download and 5mbs upload. Healthcare Fraud Shield is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.

The Special Investigations Unit (SIU) III is responsible for investigating and resolving high complexity allegations of healthcare fraud, waste and abuse (FWA) by medical professional, facilities, and members. Researches, gathers, and analyzes data to identify trends, patterns, aberrancies, and outliers in provider billing behavior. Serves as a subject matter expert for other investigators. Qualified candidates must live in Massachusetts or surrounding states. Essential Functions: Develop, coordinate and conduct strategic fact-driven investigative projects including business process review, execution of investigative activities, and development of investigation outcome recommendations Manage the development, production, and validation of reports generated from detailed claims, eligibility, pharmacy, and clinical data and translate analytical findings into actionable items Manage strategic investigative plan and drive investigative outcome for the team Ensure quality outcomes for investigative team through auditing and oversight Prioritize, track, and report status of investigations Report identified corporate financial impact issues Use concepts and knowledge of coding guidelines to analyze complex provider claim submissions Research, comprehend and interpret various state specific Medicaid, federal Medicare, and ACA/Exchange laws, rules and guidelines Identify, research and comprehend medical standards, healthcare authoritative sources and apply knowledge to investigative approach Collaborate with data analytics team and utilize RAT STATS on Statistically Valid Random Sampling Coordinate and conduct on-site and desk audits of medical record reviews and claim audits Manage and decision claims pended for investigative purposes Maintain a working knowledge of all state and federal laws, rules, and billing guidelines for various provider specialty types Prepare and conduct in-depth complex interviews relevant to investigative plan Execute and manage provider formal corrective action plans Participate in meetings with operational departments, business partners, and regulatory partners to facilitate investigative case development Participate in meetings with Legal General Counsel to drive case legal actions, formal corrective actions, negotiations with recovery efforts, settlement agreements, and preparation of evidentiary documents for litigation Present, support, and defend investigative research to seek approval for formal corrective actions Establish and maintain relationships with Federal and State law enforcement agencies, task force members, other company SIU staff and external contacts involved in fraud investigation, detection and prevention SME in the designated market and ability to apply external intelligence to their analysis and case development Develop and present internal and external formal presentations, as needed Attend fraud, waste, and abuse training/conferences, as needed Support regulatory fraud, waste, and abuse reports to federal and state Medicare/Medicaid agencies Manage and maintain sensitive confidential investigative information Maintain compliance with state and federal laws and regulations and contracts Adhere to the CareSource Corporate Compliance Plan and the Anti-Fraud Plan Assist in Federal and State regulatory audits, as needed Perform any other job-related instructions, as requested Education and Experience: Bachelor's Degree or equivalent years of relevant work experience in Health-Related Field, Law Enforcement, or Insurance required Master's Degree (e.g., criminal justice, public health, mathematics, statistics, health economics, nursing) preferred Minimum of five (5) years of experience in healthcare fraud investigations, medical coding, pharmacy, medical research, auditing, data analytics or related field is required Competencies, Knowledge and Skills: Intermediate proficiency level in Microsoft Office to include Outlook, Word, Excel, Access, and PowerPoint Effective listening and critical thinking skills and the ability to identify gaps in logic Strong interpersonal skills, high level of professionalism, integrity and ethics in performance of all duties Excellent problem solving and decision making skills with attention to details Background in research and drawing conclusions Ability to perform intermediate data analysis and to articulate understanding of findings Ability to work under limited supervision with moderate latitude for initiative and independent judgment Ability to manage demanding investigative case load Ability to develop, prioritize and accomplish goals Self-motivated, self-directed Strong written skills with ability to compose detailed investigative reports and professional internal and external correspondences Presentation experience, beneficial Knowledge of Medicaid, Medicare, healthcare rules preferred Background in medical terminology, CPT, HCPCS, ICD codes or medical billing preferred Complex project management skills preferred Display leadership qualities Licensure and Certification: One of the following certifications is required: Accredited Healthcare Fraud Investigator (AHFI) or Certified Fraud Examiner (CFE) Certified Professional Coder (CPC) is preferred NHCAA or other fraud and abuse investigation training is preferred Working Conditions: General office environment; may be required to sit or stand for extended periods of time Occasional travel (up to 10%) to attend meetings, training, and conferences may be required Compensation Range: $70,800.00 - $113,200.00 CareSource takes into consideration a combination of a candidate's education, training, and experience as well as the position's scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee's total well-being and offer a substantial and comprehensive total rewards package. Compensation Type (hourly/salary): Salary Organization Level Competencies Fostering a Collaborative Workplace Culture Cultivate Partnerships Develop Self and Others Drive Execution Influence Others Pursue Personal Excellence Understand the Business This is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.#LI-SD1

Innovative. Collaborative. Client-Focused. Growth-Minded. Caring. These are 5 words used to describe Briljent and the Briljent culture. We are seeking Adult Protective Services Investigators with these same qualities to conduct thorough investigations and document investigation activities involving allegations of abuse, neglect, and exploitation involving endangered adults Briljent is dedicated to hiring a unique team of qualified people to serve our clients. We pledge to continue building a company culture where everyone is valued and accepted. Check out our Communication Creed and Non-Negotiable Items that help define the company culture. And ask us about Never Letting Donkeys In The Pool. Must be eligible to work in the United States. No sponsorships are available currently. While this job does work remotely, this role does require on-site investigations. Travel will be required within the NE region of Indiana. Here are the day-to-day duties of this position: Investigate allegations of abuse, neglect, and exploitation involving endangered adults Conduct thorough investigations, including interviews, record reviews, and collaboration with other investigative agencies Initiate and facilitate referrals to services and community resources Document investigation activities, including case planning, safety planning, case notes, and findings Serve as the Priority A (within 24 hours of receipt) responder to initiate timely contact with clients facing immediate harm on a rotating basis Respond to all assigned investigations within the required timeframe Review and respond to quality assurance evaluations Skills needed to be successful in this role: Ability to think critically, incorporating multiple factors into larger concepts Strong organizational skills with abilities to simultaneously manage multiple investigations Ability to work with and relate to others with customer relation techniques, professionalism, and respect for other cultures Ability to effectively use active listening and interviewing skills Ability to adapt quickly when policies and regulations change Must be computer literate and have MS Word, Excel, Outlook, and Internet skills Ability to foster teamwork with all levels of management and staff Ability to work well independently and within a team Superior verbal and written communication skills Strong decision-making skills, with accuracy and attention to detail Requirements Requirements: Experience with Adult Protective Services, Investigatory, Social Services, Human Services, or Law Enforcement work Bachelor's degree preferred Must have reliable transportation, a valid drivers license, and a clean driving record Must be willing and able to commute to the following Indiana counties: Adams, Allen, Blackford, DeKalb, Elkhart, Grant, Huntington, Jay, Kosciusko, LaGrange, Noble, Steuben, Wabash, Wells, Whitley What else does it take to be successful at Briljent? Consultative Mindset -Listen. Stay client-focused. Understand and prioritize the needs, goals, and concerns of clients. Customize solutions to meet the specific requirements and expectations. Encourage open-communication and collaboration. Flexible - Be open to change and adaptable to new situations, ideas, and approaches. Learning Leader - At Briljent, we seek new ideas, find creative ways to hone skills, and share lessons learned so we can continually bring our best to our clients. It's not always easy. Honestly, it's not always comfortable. But that's okay. We love a good challenge. Impeccable Integrity - Maintain a high level of integrity, honesty and ethics in all interactions and decision making. Do what's right, do what you say you're going to do, and do it all honestly. If this sounds exciting and you have the qualifications plus something unique to add to the team, apply now! Physical Requirements & Environmental Conditions These physical demands must be met by an employee to successfully perform the essential functions of this job. The employee is regularly required to communicate, remain in a stationary position, and utilize technology tools such as a laptop computer for extended periods of time. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Equal Opportunity Employer Briljent is a solutions-based company. Solutions come from creative ideas; ideas come from being creative with differences. Briljent believes collaboration and perspective are critical to the success of the company. Employment at Briljent is based on merit and professional qualifications. We do not discriminate against any employee or applicant because of race, creed, color, religion, gender, sexual orientation, national origin, disability, age, veteran status, marital status, or any other basis protected by federal, state, or local law, regulation, or ordinance.

Full-time Description Innovative. Collaborative. Client-Focused. Growth-Minded. Caring. These are 5 words used to describe Briljent and the Briljent culture. We are seeking Adult Protective Services Investigators with these same qualities to conduct thorough investigations and document investigation activities involving allegations of abuse, neglect, and exploitation involving endangered adults Briljent is dedicated to hiring a unique team of qualified people to serve our clients. We pledge to continue building a company culture where everyone is valued and accepted. Check out our Communication Creed and Non-Negotiable Items that help define the company culture. And ask us about Never Letting Donkeys In The Pool. Must be eligible to work in the United States. No sponsorships are available currently. While this job does work remotely, this role does require on-site investigations. Travel will be required within the NE region of Indiana. Here are the day-to-day duties of this position: Investigate allegations of abuse, neglect, and exploitation involving endangered adults Conduct thorough investigations, including interviews, record reviews, and collaboration with other investigative agencies Initiate and facilitate referrals to services and community resources Document investigation activities, including case planning, safety planning, case notes, and findings Serve as the Priority A (within 24 hours of receipt) responder to initiate timely contact with clients facing immediate harm on a rotating basis Respond to all assigned investigations within the required timeframe Review and respond to quality assurance evaluations Skills needed to be successful in this role: Ability to think critically, incorporating multiple factors into larger concepts Strong organizational skills with abilities to simultaneously manage multiple investigations Ability to work with and relate to others with customer relation techniques, professionalism, and respect for other cultures Ability to effectively use active listening and interviewing skills Ability to adapt quickly when policies and regulations change Must be computer literate and have MS Word, Excel, Outlook, and Internet skills Ability to foster teamwork with all levels of management and staff Ability to work well independently and within a team Superior verbal and written communication skills Strong decision-making skills, with accuracy and attention to detail Requirements Requirements: Experience with Adult Protective Services, Investigatory, Social Services, Human Services, or Law Enforcement work Bachelor's degree preferred Must have reliable transportation, a valid drivers license, and a clean driving record Must be willing and able to commute to the following Indiana counties: Adams, Allen, Blackford, DeKalb, Elkhart, Grant, Huntington, Jay, Kosciusko, LaGrange, Noble, Steuben, Wabash, Wells, Whitley What else does it take to be successful at Briljent? Consultative Mindset -Listen. Stay client-focused. Understand and prioritize the needs, goals, and concerns of clients. Customize solutions to meet the specific requirements and expectations. Encourage open-communication and collaboration. Flexible - Be open to change and adaptable to new situations, ideas, and approaches. Learning Leader - At Briljent, we seek new ideas, find creative ways to hone skills, and share lessons learned so we can continually bring our best to our clients. It's not always easy. Honestly, it's not always comfortable. But that's okay. We love a good challenge. Impeccable Integrity - Maintain a high level of integrity, honesty and ethics in all interactions and decision making. Do what's right, do what you say you're going to do, and do it all honestly. If this sounds exciting and you have the qualifications plus something unique to add to the team, apply now! Physical Requirements & Environmental Conditions These physical demands must be met by an employee to successfully perform the essential functions of this job. The employee is regularly required to communicate, remain in a stationary position, and utilize technology tools such as a laptop computer for extended periods of time. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Equal Opportunity Employer Briljent is a solutions-based company. Solutions come from creative ideas; ideas come from being creative with differences. Briljent believes collaboration and perspective are critical to the success of the company. Employment at Briljent is based on merit and professional qualifications. We do not discriminate against any employee or applicant because of race, creed, color, religion, gender, sexual orientation, national origin, disability, age, veteran status, marital status, or any other basis protected by federal, state, or local law, regulation, or ordinance.

BMV Investigator (2600009D) Organization: Public SafetyAgency Contact Name and Information: Jennifer Pletcher, HCM Sr. Analyst - ********************** Unposting Date: Jan 22, 2026, 4:59:00 AMWork Location: BMV Toledo Inv. Office 1 Maritime Plaza Toledo 43604Primary Location: United States of America-OHIO-Lucas County-Toledo Compensation: $27.92 per hour Schedule: Full-time Work Hours: 8:00 a.m. - 5:00 p.m.Classified Indicator: ClassifiedUnion: OCSEA Primary Job Skill: InvestigationTechnical Skills: Criminology/Criminal JusticeProfessional Skills: Attention to Detail Agency OverviewBureau of Motor VehiclesOversees driver and motor vehicle licensing and registration and continues to make services more convenient, efficient and cost-effective.Job DescriptionOhio Department of Public Safety - Bureau of Motor Vehicles/Investigations District 4 ToledoReport in Location: 1 Maritime Plaza, Toledo, OH 43604Work Hours: Monday - Friday, 8:00 a.m. - 5:00 p.m.Perks of Working for the Ohio Department of Public Safety• Multiple pay increases over the first years of service!• Free Parking!What You'll Do as a BMV Investigator• Independently, or as a lead investigator, conduct criminal investigations related to allegations of fraud, abuse or other violations of ORC, OAC & BMV policy, file criminal charges & enforce Ohio motor vehicle laws & agency guidelines:• Investigate criminal acts (e.g., odometer tampering, forgeries & falsifications, possession of criminal tools, selling motor vehicles without a license, illegally obtained driver licenses, license plates, vehicle registrations & handicap parking permits);• Enforce Ohio motor vehicle laws & agency guidelines;• Locate & contact individuals whose driving &/or registration privileges have been suspended, confiscate driver licenses &/or license plates, interview individuals;• Perform investigations concerning hardship driver license &/or medical restriction cases & submit recommendations;• Participate with law enforcement & other government agencies in investigations & criminal prosecution of violators of motor vehicle laws (e.g., consult with prosecutors, file charges, present investigative case reports as a witness before the Dealer Board & testify in court).Click here to see the full position description Why Work for the State of OhioAt the State of Ohio, we take care of the team that cares for Ohioans. We provide a variety of quality, competitive benefits to eligible full-time and part-time employees*. For a list of all the State of Ohio Benefits, visit our Total Rewards website! Our benefits package includes: Medical Coverage Free Dental, Vision and Basic Life Insurance premiums after completion of eligibility period Paid time off, including vacation, personal, sick leave and 11 paid holidays per year Childbirth, Adoption, and Foster Care leave Education and Development Opportunities (Employee Development Funds, Public Service Loan Forgiveness, and more) Public Retirement Systems (such as OPERS, STRS, SERS, and HPRS) & Optional Deferred Compensation (Ohio Deferred Compensation) *Benefits eligibility is dependent on a number of factors. The Agency Contact listed above will be able to provide specific benefits information for this position.QualificationsOption 124 mos. exp. as law enforcement officer; AND valid driver's license.Option 2-Or completion of associate core program in criminology, criminal justice or law enforcement; AND 18 months experience in conducting criminal investigations. (Note: conducting criminal investigations is defined as performing field interviews & interrogation, field surveillance, field information& evidence gathering techniques while conducting investigations involving violations of criminal law(i.e., special emphasis on theft& fraud cases) as well as researching various administrative laws, policies & procedures related to commission of possible criminal offenses); AND valid driver's license.Option 3-Or 24 months experience as a Motor Vehicle Investigator Associate, 24320; AND valid driver's license.-Or equivalent of Minimum Class Qualifications For Employment noted above. Note: Pursuant to Ohio Administrative Code Chapter 4501 users of system shall adhere to policies& guidelines published in NCIC operating manual, CJIS security policy, LEADS operating manual, LEADS security policy, newsletters, & administrative messages from LEADS, all of which are either available on ODPS/LEADS intranet or disseminated to LEADS agencies; pursuant to LEADS, state& national fingerprint-based record checks must be conducted within 30 days of initial employment or assignment of all personnel, having access to LEADS, or to records storage areas containing CCH data; minimum check must include submission of both a State of Ohio BCI& I card & an FBI applicant fingerprint card; both completed applicant fingerprint cards must be submitted by employing agency to State of Ohio Bureau of Criminal Identification & Investigation for processing & forwarding to Federal Bureau of Investigation; record of this check must be kept by employing agency & made available to LEADS upon request; fingerprint card returned by Ohio BCI&I is sufficient documentation. Pursuant to Ohio Administrative Code Chapter 4501 terminal agency shall conduct a complete background investigation of all terminal operators including, but not limited to: an applicant fingerprint card submission to BCI &I & FBI, an inquiry of state& national arrest& fugitive files; terminal agency is required to notify CTO of any applicant's criminal record; existence of a criminal record may result in denial of access. Helpful Tips for Applying:1. Be detailed when describing your current/previous work duties. The more the better!! Don't just write "see attached resume".2. Tailor your application for each position you apply for. You should clearly describe how you meet the minimum qualifications outlined in this job posting.3. Respond to all questions asked. If you do not have the education/training/experience that is being asked, select either "No" or "N/A".Job Skills: InvestigationSupplemental InformationTRAINING AND DEVELOPMENT REQUIRED TO REMAIN IN THE CLASSIFICATION AFTER EMPLOYMENTMust successfully obtain LEADS certification 6 months after employment. Must re-certify in LEADS every two years as mandated by Ohio Administrative Code 4501:2-10-03 (G) (3).UNUSUAL WORKING CONDITIONSRequires travel; may be exposed to angry, hostile, or violent persons; exposed to inclement weather and elements; may work in remote rural or metro areas; may work in high-crime, hazardous &/or unsanitary environments. May conduct surveillance for extended periods of time in extreme temperatures.This position will primarily serve an area that may include (but not limited to) counties such as (Actual county assignments may vary based on coverage needs): Allen, Auglaize, Champaign, Logan, Hancock, and Hardin.This position is essential, meaning the duties this job performs are critical to the continued operations of the Ohio Department of Public Safety during a public safety emergency (OAC 123: 1-46-01 & DAS Directive HR-D-11). This position will be required to report for duty during any public safety emergency. Background Check Information• A BCI/FBI fingerprint check, and background check, may be required on all selected applicants.• A comparative analysis and/or drug-test may be a requirement of the hiring process.To request a disability accommodation, please email ************************* as soon as possible, or at least 48 hours prior to the above referenced testing or interview date so any necessary arrangements may be made in a timely manner. ADA StatementOhio is a Disability Inclusion State and strives to be a model employer of individuals with disabilities. The State of Ohio is committed to providing access and inclusion and reasonable accommodation in its services, activities, programs and employment opportunities in accordance with the Americans with Disabilities Act (ADA) and other applicable laws.Drug-Free WorkplaceThe State of Ohio is a drug-free workplace which prohibits the use of marijuana (recreational marijuana/non-medical cannabis). Please note, this position may be subject to additional restrictions pursuant to the State of Ohio Drug-Free Workplace Policy (HR-39), and as outlined in the posting.

At Quality Claims Management Corp. and our affiliate companies, we have years of expertise in representing financial institutions across a wide range of banking law matters, and we're looking for passionate, driven candidates to join our dynamic team! With offices in Arizona, Arkansas, California, Colorado, Nebraska, Nevada, New Mexico, Oregon, Texas, and Washington, we offer opportunities across multiple locations. Our workplace is more than just a job - it's a supportive, collaborative environment where your contributions truly matter. You'll be part of a team that values hard work, creativity, and dedication, while enjoying a strong sense of community. We offer performance-based bonuses, competitive compensation, and a range of incentives that reward your success. Plus, with generous benefits, enhanced employer contributions, and paid time off, we prioritize your well-being and work-life balance. Summary: Quality Claims is looking for a Junior Private Investigator to work with our investigative team. Qualified candidates are not required to be individually licensed but must be able to successfully complete the background screening necessary to become an investigator. This position provides hands-on training and experience in working actual case assignments for a private investigative agency. The candidate will perform investigations to include skip tracing, background investigations, locating subjects evading service of process, surplus funds investigations, and locating mobile assets. Key Responsibilities: Collect information, documentation, and physical evidence associated with investigations Perform online research and genealogy research Obtain records online or through state and local agencies Interview subjects and extract information Draft formal investigative reports and emails Identify and compile supporting documents Calculate billable hours worked and prepare invoices Enter notes and update files Source local investigators and process servers (nationwide) for in-personal interviews and personal service Provide other direct assistance to investigative staff throughout the investigative process May perform other duties as assigned to support department goals. May occasionally work extended hours based on operational needs. Experience and Skills: Strong written and verbal communication skills Ability to connect with people An inquisitive nature/ability to solve puzzles Strong analytical skills Strong online research skills (including social media) Familiarity with Microsoft suite of products Qualifications: Bachelor's degree in a relevant field or 1 year of investigative experience Bi-lingual (Spanish & English) preferred Work Schedule: This is a 100% office position requiring your physical presence Monday through Friday, with business hours from 8:00 AM to 5:00 PM. Salary Range: The salary for this position typically ranges from $21-$23/hour, depending on qualifications, experience, and other factors. Please note that the final offer may differ based on the candidate's specific qualifications, skills, and experience, as well as internal equity and business needs. Benefits: Quality Claims Management Corp. and affiliated companies promote work/life balance with a robust wellness program, PTO, remote work, and flexible schedules (when available). Full-time employees become eligible for benefits following a 30-day waiting period, with benefit offerings that include medical, dental, vision, life, AD&D, EAP, STD, and LTD. Additionally the firm provides parental leave for both primary and non-primary caregivers as well. Also available are voluntary income protection benefits such as supplemental life, accident, critical illness, and short and long-term care insurances, as well as a 401(k)-retirement plan with a company match. Part-time employees may have access to some of these benefits, which may be on a pro-rated basis. Security Requirement: While performing the duties of this job, the employee is required to ensure the security and confidentiality of all sensitive information, including but not limited to threats or hazards to the security or integrity of sensitive information that could result in any harm or inconvenience to any customer, employee or company. Work Environment: A corporate office environment with a professional setting, characterized by a quiet to moderate noise level. Employees may work in individual or shared workspaces, with standard office equipment such as computers, printers, and telephones. Occasional meetings, collaborative discussions, and business activities may contribute to variations in noise levels. Next Steps: Ready to take the next step? Apply now and be part of our thriving team! ************************************************************************************************************************ Id=**********673_2&lang=en_US Notices: The above information on this job description is designed to indicate the general nature and level of work performed by incumbents. Other duties and responsibilities not specifically described may be assigned from time to time, consistent with the knowledge, skills, and abilities of the incumbent. Quality Claims Management Corp. is an Equal Opportunity Employer. We are committed to providing a work environment free from discrimination and harassment. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability status, protected veteran status, or any other characteristic protected by law. We celebrate diversity and are dedicated to creating an inclusive environment for all employees. Qualified applicants with a criminal history will be considered pursuant to the San Diego County Fair Chance Ordinance, the California Fair Chance Act, and other applicable state or local laws. You do not need to disclose your criminal history or participate in a background check until a conditional job offer is made. After making a conditional offer and running a background check, if there are concerns about a conviction directly related to the job, you will be given the chance to explain the circumstances, provide mitigating evidence, or challenge the accuracy of the background report. For more information about the Fair Chance Ordinance, visit the San Diego County Office of Labor Standards and Enforcement webpage. As part of our commitment to maintaining a lawful and compliant workforce, we participate in the E-Verify program. All candidates who accept a job offer will be required to complete the E-Verify process to verify their employment eligibility in the United States. Applications will be accepted until 02/28/2026.

Applicants must live near Boise, ID. This position is responsible for comprehensive management and ownership of fraud, waste and abuse investigations including development and presentation of investigative results. This individual carries out analytical and process management tasks with a high degree of autonomy. This individual serves as a corporate resource on fraud, waste and abuse issues and recommends cost containment projects with an emphasis on fraud prevention. INVESTIGATIONS Prioritize, triage and manage workload to meet internal performance metrics, regulatory and contractual requirements Use independent judgment to create investigative work plans and develop case strategies based upon analysis of referral data and contractual/regulatory requirements Analyze data and select audit samples using various sampling methodologies Plan and conduct desk audits, field audits and/or site visits Collect and analyze information to evaluate facts and circumstances through an extensive review of data from professional and facility providers, member data, contractual relationships, payment policies, Medicaid/Medicare rules and statutes, etc. Conduct research on medical policies and practices, provider characteristics, and related topics Interview patients, providers, provider staff, and other witnesses/experts Prepare correspondence Obtain and preserve physical and documentary evidence to support investigations Maintain comprehensive case files FRAUD, WASTE AND ABUSE DETECTION Triage and prioritize leads from internal and external sources Use knowledge of healthcare coding conventions, fraud schemes, and general areas of vulnerability, reimbursement methodologies, and relevant laws to find suspicious patterns in claims data, provider enrollment data, and other sources Remain up to date on published fraud cases, schemes, investigative techniques and methodologies, and industry trends PACKAGING OF FINDINGS AND RECOMMENDATIONS Organize data and prepare a written summary of investigative steps, conclusions, recommendations with attention to detail and a high level of accuracy Prepare clear and concise investigatory reports to support findings of potential fraud, waste and abuse CASE RESOLUTION Identify, communicate and recover losses as deemed appropriate Present case to internal department(s), law enforcement and/or regulatory agencies Support legal proceedings as needed, including testifying in court or working with law enforcement personnel to prepare cases for civil or criminal actions Negotiate settlement agreements with subjects and/or attorneys Assist in preparation, execution, and follow-up of settlement agreement terms CUSTOMER INTERACTIONS Make presentations to customers, prospects, conference audiences, and law enforcement Collaborate, consult, and coordinate regularly with clients on the status and direction of assignments Develop and maintain contacts/liaisons with law enforcement, regulatory agencies, task force members, other company SIU staff and external contacts involved in fraud investigation, detection and prevention MISCELLANEOUS DUTIES Represent client at industry task force meetings and meetings with regulatory agencies Measure and report performance metrics Identify opportunities and make recommendations for reduction of exposure to fraud, waste and abuse Consult on anti-fraud policies and procedures Other duties as assigned The job duties listed above are representative and not intended to be all-inclusive of what may be expected of an employee assigned to this job. A leader may assign additional or other duties which would align with the intent of this job, without revision to the job description. Other Job Requirements Responsibilities Minimum of five years of experience in fraud investigations, related behavioral or medical healthcare insurance experience in claims, clinical, auditing, compliance, provider networks, management, or project planning. Demonstrated abilities in time management and establishing priorities. Strong listening and observation skills. Impeccable work ethic, completely dependable, and proactive; a problem solver. Proven ability to effectively handle cases of fraud and abuse in a discreet, confidential, and professional manner. Demonstrated strategic and analytical thinking skills, with ability to effectively communicate conclusions and recommendations to management. Comprehensive, practical knowledge of complex and diverse fraud investigative techniques and methodologies utilized in program audits. Understanding of insurance terms and policy interpretation. Ability to work to tight timelines when necessary. Works independently; collaborates well with peers and customers. Demonstrated ability to manage and prioritize case load with limited supervision. Strong computer skills consisting of Microsoft Excel, Access, Outlook, Word, and Power Point. General Job Information Title SIU Program Integrity Investigator - Remote (In Idaho) Grade 24 Work Experience - Required Fraud Investigations Work Experience - Preferred Education - Required A Combination of Education and Work Experience May Be Considered., Bachelor's Education - Preferred License and Certifications - Required License and Certifications - Preferred AHFI - Accredited Healthcare Fraud Investigator - EnterpriseEnterprise, CFE - Certified Fraud Examiner - EnterpriseEnterprise, CPC - Certified Professional Coder - EnterpriseEnterprise, LSSBB - Lean Six Sigma Black Belt Certification - EnterpriseEnterprise, RN - Registered Nurse, State and/or Compact State Licensure - Care MgmtCare Mgmt Salary Range Salary Minimum: $58,440 Salary Maximum: $93,500 This information reflects the anticipated base salary range for this position based on current national data. Minimums and maximums may vary based on location. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law. This position may be eligible for short-term incentives as well as a comprehensive benefits package. Magellan offers a broad range of health, life, voluntary and other benefits and perks that enhance your physical, mental, emotional and financial wellbeing. Magellan Health, Inc. is proud to be an Equal Opportunity Employer and a Tobacco-free workplace. EOE/M/F/Vet/Disabled. Every employee must understand, comply with and attest to the security responsibilities and security controls unique to their position; and comply with all applicable legal, regulatory, and contractual requirements and internal policies and procedures.

Competitive Compensation & Benefits Package! eligible for - Annual incentive bonus plan Medical, dental, and vision insurance with low deductible/low cost health plan Generous vacation and sick time accrual 12 paid holidays State Retirement (pension plan) 401(k) Plan with employer match Company paid life and disability insurance Wellness Programs Public Service Loan Forgiveness Qualifying Employer See attachment for additional details. Office Location: Flexible for any of our NC office locations (Must live in NC or within 40 miles of NC border) Projected Hiring Range : Depending on Experience Closing Date: Open Until Filled Primary Purpose of Position: This position will assist in the development, implementation, revision, maintenance, and promotion of the agency's fraud, waste, and abuse prevention and detection activities to ensure that the agency and the agency's network operates in a manner that complies with applicable State and Federal laws, regulations, agency policies, national accreditation, and Medicaid guidelines. This position will perform functions relating to data analysis, investigations, and auditing relating to the monitoring, detection, and resolution of healthcare fraud, waste, and abuse. Role and Responsibilities: Conduct, plan and perform independent and comprehensive audits, investigations and reviews (hereinafter referred to as investigations) into allegations of regulatory compliance violations, including fraud, waste, and abuse (FWA). Investigation includes the review of financial, consumer/clinical, provider, and/or other records, reports, and information necessary to thoroughly analyze and investigate suspected violations. Conduct clinical and non-clinical interviews, as necessary, to facilitate the investigative process. Work collaboratively with appropriate internal/external subject matter experts, agency and provider personnel, as necessary, to facilitate the investigative process. Conducts clinical chart reviews of instances of care authorized for utilization purposes, case reviews for individuals that are identified as either over or under-utilizers of services. Knowledge of documentation and clinical protocols for utilization purposes and case reviews for individual consumers in order to conduct clinical chart reviews. Clinical knowledge of managed systems of physical health services (professional and institutional), durable medical equipment, pharmacy, Mental Health, substance abuse, and Intellectual and Developmental Disabilities to also include co-occurring disorders. Knowledge of managed care practices and principles to detect fraud, waste and abuse. Clinical ability to recognize gaps in Partners Health Management service network and ability to communicate these identified gaps to appropriate parties. Serve as a Lead Investigator responsible for coordinating and leading agency investigative teams related to program integrity. Gather, evaluate, and synthesize evidence related to reported allegations to determine compliance with applicable state and federal policies, laws, and regulations. Prepare written and oral reports based on the results of assigned work that help to sustain findings and uphold disputed TNOs. Prepare timely, thorough, and accurate investigative reports; compile case file documentation; calculate overpayments; and synthesize findings in accordance with agency policies and procedures and departmental guidelines. Communicate effectively, both in writing and orally, to ensure accurate and timely completion of all assignments. Develop, implement, monitor, and maintain analytic reports to detect and prevent health care FWA. Conduct independent data mining and data analysis techniques utilizing claims data to detect abnormal claims and develop trends and patterns for potential cases. Independently prepare case documents for referral to the appropriate oversight agency and other external agencies involved in the prosecution of health care fraud. Manage cases from complaint intake through their ultimate conclusion, including supporting the case during all legal processes and appeals and the collection of final overpayments. Create, maintain, and manage cases within the case filing and tracking systems to ensure information is accurate, timely and complete. Consult with legal counsel in order to prepare testimony and other information necessary for appeals and as requested by external agencies investigating or prosecuting Medicaid fraud (as appropriate). Remain abreast of all federal and North Carolina rules and laws applicable to FWA and program integrity. Develop and conduct proactive audits, reviews and investigations of Partners' programs to facilitate the detection and resolution of FWA. Develop, coordinate, and facilitate educational training to the Provider Network and agency personnel on issues relating to the compliance program, FWA. Identify information system edits/alerts/reports in need of implementation in the claims processing system(s). Recommend and implement compliance initiatives, policies, procedures, and practices designed to promote and encourage the reporting of suspected FWA without fear of retaliation. Serve on and/or facilitate various agency committees as deemed necessary by the Program Integrity Director Use data collection instruments and protocols previously developed or adopted by the department and develop data collection instruments as needed for complex investigations. Analyze computer-generated data sets, including claims data, to identify individuals and organizations that are most likely to provide evidence to ascertain whether FWA is likely to have occurred. Develop summary reports that illustrate data analysis to a nonscientific audience. Use appropriate software and systems to complete work assignments. Consult with IT to manage data and generate needed program reports. Perform other duties as assigned. Knowledge, Skills and Abilities: Strong knowledge of state and federal laws, including those related to Medicaid FWA, and regulatory compliance are required. Knowledge of investigative methods and procedures. Knowledge of claims processing and clinical services. Excellent interpersonal and communication skills. Excellent analytical skills. Effective time management and organizational skills. Excellent conflict management skills. Proficient in Word, Excel, Outlook, and Power Point. Ability to learn and effectively manage various information systems including Partners' claims reporting and North Carolina TRACKS. Ability to develop solutions and make recommendations for necessary process improvements. Ability to interpret contractual agreements, business oriented statistics, clinical/administrative services and records. A high level of integrity and discretion is required to effectively carry out the responsibilities related to this position. Education and Experience Required: Master's degree in a Human Services field, Health Administration, health informatics/analytics, or related field, OR a Bachelor's of Science in Nursing and licensed to practice as a Registered Nurse in North Carolina by the N. C. Board of Nursing. Minimum of 3 years recent experience in the healthcare field with compliance monitoring, auditing or investigation experience. Licensed Clinical Social Worker, Licensed Clinical Mental Health Counselor, Licensed Clinical Addiction Specialist, Registered Nurse, Nurse Practitioner, Physician's Assistant, or another clinical license related to the healthcare field. Education and Experience Preferred: Five years recent experience in the healthcare field. Experience analyzing complex data, claims processing, utilization reviews, provider credentialing/monitoring, and/or fraud and abuse detection. Preferred credentials: Registered Health Information Technician (RHIT); Registered Health Information Administrator (RHIA); Certified Coding Specialist (CCS); Certified Fraud Examiner (CFE); and/or Accredited Healthcare Fraud Investigator (AHFI) certification. Licensure/Certification Requirements: Current unrestricted LCSW, LCMHC, LPA, LMFT or LCAS licensure with the appropriate professional board of licensure in the state of North Carolina or licensed to practice as a Registered Nurse, Nurse Practitioner in North Carolina by the N. C. Board of Nursing or licensure in the State of North Carolina or licensed to practice as a Physician's Assistant by the North Carolina Medical Board. Employee is responsible for complying with respective licensure board's continuing education/ training requirements in order to maintain an active license. Must maintain licensure or certification.

LOCATION: Remote -must live in North Carolina or within 40 miles of the NC border. This position is remote, but the applicant must be able to travel to Vaya's Offices or within Vaya's Catchment area as needed . GENERAL STATEMENT OF JOB The Special Investigator works under the direct supervision of the SIU Manager. The Special Investigator is responsible for identification, investigation and prevention of healthcare fraud, waste and abuse within the Vaya Health Network of contracted providers. The Special Investigator will develop investigative summary reports and make applicable referrals to the NC Division of Health Benefits, and recommendations as necessary to providers associated with investigation findings/outcomes. ESSENTIAL JOB FUNCTIONS Investigative Activities: Utilize established Vaya procedures to conduct inquiries and investigations into complaints, allegations, and referrals regarding suspected Fraud, Waste or Program Abuse Review healthcare claims to determine if provider payments were rendered in accordance with rules, regulations, service definition, service utilization, and contractual requirements Determine correct coding, billing, documentation, delivery of services and potential violations of federal and/or state regulation or Medicaid guidelines Perform reviews (desk, virtual, and/or on-site)interview providers, members, and stakeholders, and review medical records to verify compliance with program policies and/or standards of health care, appropriateness of services or medical necessity Prepare reports and exhibits from the findings of provider investigations and develop recommendations or intervention strategies to correct or prevent abusive practices, including proposals to recover inappropriately paid moneys or to suspend or terminate program participation. Refer suspected fraud cases to the DHB Office of Compliance and Program Integrity Administrative Activities: Participate in both informal and formal appeal processes, defending their decisions before a Vaya reconsideration panel, hearing officers and/or administrative law judges Provide litigation testimony as applicable Work in conjunction with various regulatory bodies Propose new fraud prevention edits for automated claims/billing system when new fraudulent schemes are discovered Support Activities: Other duties including technical assistance and provider education may be assigned based upon need, area of expertise, special interests and availability of resources. KNOWLEDGE, SKILLS, & ABILITIES Knowledge of healthcare service definitions, service documentation, and service utilization requirements An intermediate level of knowledge of Local, State and Federal laws and regulations pertaining to insurance and/or healthcare services Possess comprehensive knowledge of fraud investigative procedures and judicial processes relating to fraud prosecutions Excellent decision-making abilities to determine the appropriate course of action during investigations and subsequent follow-up Ability to prepare detailed and comprehensive reports, to present facts clearly, and to instruct others in new methods and procedures; Excellent written communication skills for correspondence, case documentation and report writing Extensive oral and written communication with providers, state and federal regulatory agencies, licensing entities, independent contractors, and members Present investigative findings with regulatory violations citations and ability to accurately describe scheme(s) to defraud Medicaid Intermediate or better proficiency with Microsoft Word, Microsoft Outlook, and Excel and ability to adapt to new technologies and platforms Ability to work autonomously, exercising sound judgment and problem resolution skills Ability to establish appropriate and respectful relationships/partnerships with persons with a wide range of ethnicities and abilities EDUCATION & EXPERIENCE REQUIREMENTS Associate degree in Compliance, analytics, government/public administration, auditing, security management or pre-law, psychology, social work, arts, science or a related human service field. Bachelor's degree preferred. Must have three (3) years of experience in compliance, healthcare, or fraud investigation unit. Preferred work experience: Four years of Medicaid Behavioral Health and/or physical health service delivery Preferred Licensure/Certification: Qualified Professional, Accredited Healthcare Fraud Investigator, Certified Fraud Examiner, or Certified Professional Coder preferred. PHYSICAL REQUIREMENTS: Close visual acuity to perform activities such as preparation and analysis of documents; viewing a computer terminal; and extensive reading. Physical activity in this position includes crouching, reaching, walking, talking, hearing and repetitive motion of hands, wrists and fingers. Sedentary work with lifting requirements up to 10 pounds, sitting for extended periods of time. Mental concentration is required in all aspects of work. RESIDENCY REQUIREMENT: The person in this position is required to reside in North Carolina or within 40 miles of the North Carolina border. SALARY: Depending on qualifications & experience of candidate. This position is exempt and is not eligible for overtime compensation. DEADLINE FOR APPLICATION: Open Until Filled APPLY: Vaya Health accepts online applications in our Career Center, please visit ****************************************** Vaya Health is an equal opportunity employer.