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Clinical Investigator (Full-Time Remote, Mecklenburg County, North Carolina Based)
Alliance 4.8
Remote crime scene investigator job
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
$77.9k-99.3k yearly 15d ago
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Experienced AML Investigator - Financial Crimes - Remote
AML Rightsource 3.6
Remote crime scene investigator job
Remote - Florida
Remote - Georgia
Remote - North Carolina
Remote - Ohio
Remote - Oklahoma
Remote - Pennsylvania
Remote - South Carolina
Remote - Tennessee
Remote - Texas
Work Arrangement:
This is a remote, work-from-home opportunity for candidates located in one our eligible states. The role includes three weeks of company-provided remote training.
Please note: Remote work flexibility is not guaranteed long-term and may be subject to change based on company needs.
(Candidates must currently reside in Arizona, Florida, Georgia, North Carolina, Ohio, Oklahoma, Pennsylvania, South Carolina, Tennessee, or Texas).
About the Role:
As a Senior AML Investigator, you'll work remotely to provide expertise in detecting suspicious financial activity, ensuring regulatory compliance, and performing quality control. You will lead investigations, supervise junior analysts, and collaborate with clients to manage financial crime risks. This role offers the opportunity to work independently while making key decisions in a fast-paced, dynamic environment.
Key Responsibilities:
Identify data anomalies and red flags related to money laundering, terrorist financing, fraud, and sanctions violations, escalating cases for second-level review as appropriate.
Verify client identities to understand the nature and purpose of their relationship with the financial institution, ensuring compliance with Know Your Customer (KYC) procedures.
Perform quality control (QC) tasks as needed.
Assist with advanced responsibilities, including client communication, analyzing production data, and developing client-specific aids and training materials.
Provide independent support to analysts with workflow items and administrative tasks as they arise.
Submit written work for review by internal and client quality control teams, make necessary adjustments based on feedback, and apply insights to future work.
Meet all designated deadlines and procedures to ensure accurate and timely completion of tasks.
Contribute to a collaborative, team-oriented work environment.
Comply with all relevant federal and state laws, regulations, and guidance, including Anti-Money Laundering (AML) requirements, as well as company policies, procedures, and client expectations.
What You Bring (Minimum Qualifications)
Bachelor's degree is required.
At least 2-3 years of relevant AML/BSA experience.
Must currently reside in Arizona, Florida, Georgia, North Carolina, Ohio, Oklahoma, Pennsylvania, South Carolina, Tennessee, or Texas
Ability to thoroughly investigate potentially suspicious activities, analyze findings, and prepare detailed Suspicious Activity Reports (SARs) in compliance with regulatory requirements and clients' internal policies.
Strong knowledge of financial or banking industries and related regulations and laws.
Strong written and oral communication skills with the ability to produce narrative or written summaries clearly synthesizing recommendations and conclusions.
Proven ability to consistently meet and exceed daily production goals, demonstrating strong time management skills, attention to detail, and the capacity to prioritize tasks effectively.
Strong analytical, problem solving and organizational skills.
Proficiency in Microsoft Excel, PowerPoint, and Word, with a demonstrated ability to quickly learn new technologies.
Demonstrated experience in MS Excel, including pivot tables, macros, filtering, and sorting.
Capable of multitasking, working independently, and collaborating as part of a team to establish cooperative and productive working relationships.
Receptive to feedback and able to implement changes effectively.
Quick learner with adaptability to new technologies and processes.
Normal Working Hours and Conditions:
Core hours are 8:00 am - 5:00 pm, with potential flexibility required based on operational needs across different time zones.
About Us:
We are AML RightSource, the leading technology-enabled managed services firm focused on fighting financial crime for our clients and the world. Headquartered in Cleveland, Ohio, and operating across the globe, we are a trusted partner to our financial institution, FinTech, money service business, and corporate clients.
Using a blend of highly trained anti-financial crime professionals, cutting-edge technology tools, and industry-leading consultants, we help clients with their AML/BSA, transaction monitoring, client onboarding (KYC), enhanced due diligence (EDD), and risk management needs.
We support clients in meeting day-to-day compliance tasks, urgent projects, and strategic changes. Globally, our staff of more than 7,000 highly trained analysts and subject matter experts is the industry's largest group of full-time compliance professionals. Together with our clients, we are Reimagining Compliance.
Compensation & Benefits
Salary Range: $43,888 - $69,000 annually (based on experience).
Comprehensive health, dental, and vision benefits.
Paid time off and holidays .
Professional development opportunities .
Collaborative work environment with global exposure.
Physical Requirements:
Ability to sit or stand for long periods.
Prolonged use of computers and office equipment.
Occasional lifting, bending, and reaching required.
About Us
AML RightSource is the leading technology-enabled managed services firm focused on fighting financial crime. Headquartered in Cleveland, Ohio, we operate globally as a trusted partner to financial institutions, FinTechs, and corporations.
Our team of 7,000+ compliance professionals combines expertise, technology, and consulting to help clients with AML/BSA, transaction monitoring, KYC, EDD, and risk management. Together, we are Reimagining Compliance.
AML RightSource, LLC will not provide sponsorship for employment visas or participate in STEM OPT for this position.
AML RightSource may use AI tools to support candidate screening; however, all hiring decisions are made through human review.
We are committed to providing accommodations to individuals with disabilities throughout all aspects of the recruitment process. If you require accommodation to participate in the recruitment and selection process, please email ************************* or discuss your needs when contacted for an interview.
AML RightSource is committed to fostering a diverse work environment and is proud to be an equal opportunity employer. We provide equal employment opportunities to all qualified applicants without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state, or local laws.
Recruitment Scam Alerts
We're aware of an increase in recruitment scams where individuals falsely claim to represent AML RightSource. These scammers may ask for money or personal information by offering fake job opportunities through e-mail, text message or social media. Please verify the source of any job-related communications carefully. All official AML RightSource communications are conducted through "@amlrightsource.com" email addresses. If you encounter suspicious messages, do not respond.
$43.9k-69k yearly Auto-Apply 14d ago
Detectives and Criminal Investigators - AI Trainer (Contract)
Handshake 3.9
Remote crime scene investigator job
Handshake is recruiting Detectives and Criminal Investigator Professionals to contribute to an hourly, temporary AI research project-but there's no AI experience needed. In this program, you'll leverage your professional experience to evaluate what AI models produce in your field, assess content related to your field of work, and deliver clear, structured feedback that strengthens the model's understanding of your workplace tasks and language. The Handshake AI opportunity runs year-round, with project opportunities opening periodically across different areas of expertise.
Details
The position is remote and asynchronous; work independently from wherever you are.
The hours are flexible, with no minimum commitment, but most average 5-20 hrs
The work includes developing prompts for AI models that reflect your field, and then evaluating responses.
You'll learn new skills and contribute to how AI is used in your field
Your placement into a project will be dependent on project availability-if you apply now and can't work on this project, more will be available soon.
Qualifications
You have at least 4 years of professional experience in one or more of the following types of work.
The examples below reflect the types of real-world responsibilities that you might have had in your role that will give you the context needed to evaluate and train high-quality AI models
Conduct thorough investigations by collecting and analyzing evidence, interviewing witnesses and suspects, and documenting findings in detailed reports.
Secure crimescenes, collaborate with other agencies, and prepare for court proceedings.
Engage in surveillance and undercover operations, utilizing specialized equipment and techniques to gather critical information.
You're able to participate in asynchronous work in partnership with leading AI labs.
Application Process
Create a Handshake account
Upload your resume and verify your identity
Get matched and onboarded into relevant projects
Start working and earning
Work authorization information
F-1 students who are eligible for CPT or OPT may be eligible for projects on Handshake AI. Work with your Designated School Official to determine your eligibility. If your school requires a CPT course, Handshake AI may not meet your school's requirements. STEM OPT is not supported. For more information on what types of work authorizations are supported on Handshake AI.
$42k-71k yearly est. Auto-Apply 14d ago
Travel Sub-Investigator
Care Access 4.3
Remote crime scene investigator job
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: ********************************
$130k-165k yearly Auto-Apply 8d ago
Investigator II
Elevance Health
Crime scene investigator job in Columbus, OH
**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.
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.
$69.4k-104.2k yearly 13d ago
Sr Investigative Analyst
Victoria's Secret 4.1
Crime scene investigator job in Reynoldsburg, OH
Senior Investigative Analyst The Senior Investigative Analyst (Sr. IA) is a highly dependable position in the Asset Protection Department. The Sr. IA is responsible for reducing shrink through the identification and development of internal/external theft investigations managing the restitution procedures and vendor partnership and supporting background checks adjudication.
The Sr. IA needs to be analytical and detail oriented. The role requires the ability to transition from daily tasks to managing ad-hoc requests by the leadership and field team members with agility and speed to meet deadlines.
The Sr. IA will maintain a peer mentorship traveling as needed, to visit stores, attended industry conferences as directed, enhance product knowledge, and develop business acumen through such partnerships. In addition, the Sr. IA will assist and support multiple vendor partnerships in the areas of exception-based reporting, restitution, and background checks.
The Sr. IA must have strong customer services skills and be able to manage workload to complete tasks with minimal supervision at times. The Sr. IA must be able to analyze data from multiple sources and consistently building new/refining existing reports. The Sr. IA needs to be self-motivated to challenge themselves by developing new skills, leverage emerging technologies, and act as leader within the Asset Protection Operations Team. The Sr. IA needs to be willing to make recommendations or call outs based on the analysis trends and results. The Sr. IA reports to the Senior Manager of Asset Protection Analytics, working a hybrid schedule with a minimum of three days in office per week.
Why You Belong Here
At Victoria's Secret & Co, you'll join a world-leading specialty retail brand recognized globally for innovation and excellence in lingerie and fashion. You'll work alongside industry leaders to set the standard for what a retail brand can achieve, placing customers at the center of everything we do to create products and experiences that bring them joy.
We believe everyone deserves a place where they truly belong. We celebrate individuality and know that your passion, experience, and unique perspective strengthen our team and business. Here, you'll be empowered to perform, grow, and engage through unmatched opportunities to develop your skills, gain real-world experience, and learn from the best in the business.
Essential Functions/Core Responsibilities:
* Shrink reduction and prevention.
* Internal/external case identification and development.
* Data/trend analysis (POS, Internal Investigations, RFID, and background checks).
* Restitution/collections (reporting, field compliance, and vendor partnerships).
* Background check support.
* Other duties as assigned.
The Sr. IA will work on special projects involving various teams within the Asset Protection Department. The Sr. IA analyst will collaborate with members across the Asset Protection team as well as other cross-functional partners in the company.
Click here for benefit details related to this position.
Minimum Salary: $58,000.00
Maximum Salary: $76,125.00
VS&Co provides a range of compensation for this role as shown. Your actual salary will be determined by a number of factors, including: your specific skills and experience, geographic region, or other relevant factors.
Qualifications
Your Experience
* 7-10 years of relevant work experience in retail or asset protection.
* 5 years' experience conducting retail investigations with a focus on internal/external theft and ORC.
* 2 years' experience of managing complex projects and vendor partnerships.
* Advanced understanding of POS analysis, inventory systems, case management software, and exception-based reporting.
* Experience managing and/or system administration support of AP software.
* Proficient in Microsoft Office (i.e., Excel, PowerPoint, Outlook).
* Strong team leadership, relationship building cross-functional partnership.
* Excellent organizational, verbal, and written communication skills.
* Must be able to work onsite Tuesday, Wednesday, and Thursday.
* Must be able to travel quarterly to stores for special projects
#LI-WM1
We will consider for employment all qualified applicants, including those with arrest records, conviction records, or other criminal histories, in a manner consistent with the requirements of any applicable state and local laws. Please see links: California Fair Chance Act, Los Angeles Fair Chance Initiative for Hiring Ordinance, Philadelphia Fair Chance Law, San Francisco Fair Chance Ordinance, Los Angeles County Fair Chance Ordinance
An equal opportunity employer, we do not discriminate in hiring or terms and conditions of employment because of an individual's race, color, religion, gender, gender identity, national origin, citizenship, age, disability, sexual orientation, marital status or any other protected category recognized by state, federal or local laws. We only hire individuals authorized for employment in the United States.
$58k-76.1k yearly 31d ago
Contract Investigator - Columbus, OH
Omniplex World Services Corporation, A Constellis Company
Crime scene investigator job in Columbus, OH
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.
$50k-89k yearly est. 60d+ ago
Investigator
Ethos Risk Services
Crime scene investigator job in Columbus, OH
ABOUT US: Ethos Risk Services is a leading insurance claims investigation and medical management company, specializing in surveillance and fraud detection. At the forefront, we provide accurate data and actionable insights that translate into better decision-making for our clients.
JOB SUMMARY:
Our dynamic Ethos team is seeking an Experienced Field Investigator to conduct surveillance and investigative activities to identify potential fraudulent insurance claims. This role involves performing both stationary and mobile surveillance, obtaining video and photographic evidence, and preparing thorough, detailed reports for clients.
KEY RESPONSIBILITIES:
Case Preparation: Prepare for surveillance assignment by reviewing Ethos' preliminary reports and case information.
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 file by submitting case reports and uploading video footage via personal laptop at the end of the day.
Communication: Work closely with the field supervisor and operations teams, receiving regular guidance and mentorship.
REQUIREMENTS:
Previous Experience: Demonstrated proficiency in covert surveillance techniques, capturing high-quality video footage, and preparing thorough, well-organized investigative reports.
Driver's License: Valid driver's license and proof of automobile insurance.
Personal Vehicle: A well-maintained vehicle that is always reliable (preferably with tinted windows).
Surveillance Equipment: A handheld camcorder with high-quality zoom and a covert camera device. Use of stabilization equipment (gimbals, tripods, etc.) is strongly encouraged.
Technology: A reliable laptop, cell phone, and internet service are needed for communication and administrative tasks.
Private Investigator License: Active Private Investigator license or willingness to obtain one (where required by state).
WORKING CONDITIONS:
While we aim to keep assignments within a 2-hour drive of your residence, occasional further travel and overnight stays (covered by the company) may be required
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.
$50k-89k yearly est. 22d ago
SIU Investigator (Field)- Miami, FL
TWAY Trustway Services
Remote crime scene investigator job
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.
$54k-93k yearly est. Auto-Apply 9d ago
Affirmative Civil Enforcement (ACE) Investigator
Contact Government Services, LLC
Remote crime scene investigator job
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
$54k-93k yearly est. Auto-Apply 60d+ ago
SIU Investigator
Healthcare Fraud Shield
Remote crime scene investigator job
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.
$47k-84k yearly est. 27d ago
SIU Investigator III (Must live in MA or surrounding states)
Caresource 4.9
Remote crime scene investigator job
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
$70.8k-113.2k yearly Auto-Apply 36d ago
Crime Scene Cleanup Technician
Bio Recovery
Crime scene investigator job in Columbus, OH
Benefits:
Earn $20-35+/hour including hourly wages, fixed compensation and bonuses
Health/dental/vision insurance
Paid time off
Opportunities for professional development and growth
Description:
We are seeking an EXPERIENCED remediation professional to serve as a CrimeScene Cleanup Technician to help clean and remediate environments contaminated by events such as suicides, homicides, unattended deaths, hoarding, accidents, and similar situations. Biorecovery is a leading national provider of biohazard remediation and cleaning services. With a strong commitment to safety, professionalism, and compassion, we assist individuals and communities in recovering from traumatic incidents.
Please note that we are only considering applicants with previous experience in remediation of any type. Some biohazard experience is preferred, but not required. Applicants with work experience from other biohazard remediation companies are strongly preferred! Please make sure your resume is up to date!
If you are hard-working and willing to travel to the scene of these emergencies, join our team and be a part of a vital mission to serve others in their time of need.
Key Responsibilities:
Be on call 24/7 to be dispatched to emergencies whenever they arise.
Must be flexible with multi-day travel to neighboring states if the cleanup job calls for this work.
Take direction from the on-site CrimeScene Cleanup Supervisor to properly dispose of biohazardous waste according to regulations and company protocols.
Use personal protective equipment (PPE) and follow safety procedures at all times.
Document and photograph work before and after remediation.
Maintain equipment and supplies in excellent condition.
Demonstrate empathy and respect for the emotions of clients facing difficult situations.
Qualifications:
Previous experience in remediation or related fields is required
Be available on-call 24 hours a day, 7 days a week to respond to dispatch within a reasonable time
Be able to see and smell unpleasant contaminants without feeling sick or upset
Ability to lift up to 50lbs preferred
Valid driver's license and an acceptable driving record
Comfortable working in emotionally charged environments with compassion and professionalism
Compensation: $20.00 - $35.00 per hour
Bio Recovery is a nationwide biohazard cleanup company providing 24/7 emergency services to homes, businesses, and communities in need.
$20-35 hourly Auto-Apply 60d+ ago
APS Investigator - Region 2 (Northeast)
Briljent LLC
Remote crime scene investigator job
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.
$36k-64k yearly est. 23d ago
APS Investigator - Region 2 (Northeast)
Briljent
Remote crime scene investigator job
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.
$38k-67k yearly est. 23d ago
Crime Scene Technician
Dasstateoh
Remote crime scene investigator job
CrimeScene Technician (260000C1) Organization: Attorney GeneralAgency Contact Name and Information: Tina.Webb@ohio AGO.gov Unposting Date: Jan 27, 2026, 4:59:00 AMPrimary Location: United States of America-OHIO-Franklin CountyOther Locations: United States of America-OHIO-Ashland County, United States of America-OHIO-Pickaway County, United States of America-OHIO-Marion County, United States of America-OHIO-Delaware County, United States of America-OHIO-Licking County, United States of America-OHIO-Knox County, United States of America-OHIO-Richland County, United States of America-OHIO-Hocking County, United States of America-OHIO-Fairfield County, United States of America-OHIO-Ross County, United States of America-OHIO-Morrow County, United States of America-OHIO-Union County Compensation: $33.09/hr-$46.63/hr Schedule: Full-time Work Hours: Variable/Non-StandardClassified Indicator: ClassifiedUnion: Attorney General FOP Primary Job Skill: InvestigationTechnical Skills: InvestigationProfessional Skills: Attention to Detail, Collaboration, Critical Thinking, Decision Making, Confidentiality Agency OverviewAbout Us:The Ohio Attorney General's Office has played a vital role in shaping Ohio's past and present and the work it does today helps chart the state's future. The office consists of nearly 30 distinct sections that advocate for consumers and victims of crime, assist the criminal justice community, provide legal counsel for state offices and agencies, and enforce certain state laws. In these and other capacities, staff members interact with tens of thousands of Ohioans each year.Job DutiesWhat you'll do:The Ohio Attorney General's Office is currently seeking a public minded individual for CrimeScene Technician vacancy in the Bureau of Criminal Investigation (BCI) Section within the CrimeScene Unit. This position will primarily be designated for remote working. There may be in person requirements for training and operational needs. The headquarter location is London, OH. The Bureau of Criminal Investigation, known as BCI, houses the state's official crime lab and identification services serving all of Ohio, as well as the criminal justice community. BCI also provides expert criminal investigative services to local, state, and federal law enforcement agencies upon request. With offices throughout the state, BCI stands ready to respond 24/7 to law enforcement agencies' needs. Staff at BCI work every day to provide the highest level of service. This includes special agents who are on call 24/7 to offer investigative assistance to law enforcement, knowledgeable scientists and forensic specialists using cutting-edge technology to process evidence to bring criminals to justice, and criminal intelligence analysts and identification specialists who help local law enforcement solve cases. Experienced special agents, forensic scientists, and other law enforcement experts' staff BCI's three main divisions: 1) Identifications 2) Investigations and 3) Laboratory. The successful candidate must reside in or be willing to relocate within 90 days to one of the following counties: Ashland, Delaware, Fairfield, Franklin, Hocking, Knox, Licking, Marion, Morrow, Pickaway, Richland, Ross, and Union counties only.The duties for this position include, but are not limited to, the following:Distinguishes the full range of the color spectrum in order to visually and physically examine and investigate all types of crimescenes including, but not limited to: burglaries, vehicle crimes, thefts, assaults, abuse, thefts, criminal damage, officer involved critical incidents and death investigations, for the recognition, collection and preservation of physical evidence such as latent fingerprints, shoe prints and tire tracks, body fluids (such as blood), hair and fibers, weapons and other materials in sometimes stressful and unpleasant environments.Utilizes a two-way radio, MDC, and phone in order to communicate withdiverse groups of people, both verbally and in writing, often under stressful circumstances.Handles situations tactfully with co-workers and citizens while demonstrating mutual respect for people of all levels.Answers questions to a variety of inquiries over the phone and in person, to provide information on policies, procedures, and resolve questions or problems related to area of assignment.Conducts area searches on foot or in a vehicle.Recovers, unloads and impounds firearms and other weapons using sound safety precautions.Recovers, transports, and impounds various types of evidence, including, but not limited to human remains.Measures and makes advanced mathematical calculations and diagrams complex crimescenes.Prepares and utilizes presumptive tests, various chemicals, powders, compounds and casting materials used in a forensic laboratory, preserving techniques as required.Photographs various types of crimescenes and evidence, as well as postmortem examinations.Utilizes specialized equipment and procedures to determine the presence of body fluidsand to collect body fluids, hair, fibers, gunshot residue and other trace evidence and materials.Dusts for and completes lifts for fingerprints.Casts shoe impressions and other evidence preserving techniques as required.Conducts interviews to gain relevant information for crimesceneinvestigations or other investigations as necessary.After compiling all the necessary information for the assigned crimesceneinvestigation, enters the detailed information into a computerized report writing program using appropriate grammar, punctuation, and report writing styles.Drives to crimescenes to conduct investigations using a state issued vehicle from residential office or other agreed upon location.May be required to testify in court in connection to scenes processed and evidence collected and preserved.May provide specialized field training and/or training in crimescene preservation to Police Officers, Police Aides and citizens.May render an opinion and draw conclusions utilizing skills in a respective subdiscipline such as footwear comparisons, bloodstain pattern interpretation and bullet trajectory paths.Completes and passes annual proficiency testing in various aspects of crimescene processing.Completes and passes competency testing as required.Required to carry a firearm.Performs other duties as assigned.QualificationsCompletion of bachelor's degree in forensic science or in a field related to crimesceneinvestigation; 2 years of experience in crimesceneinvestigation; valid driver's license.-Or equivalent of Minimum Class Qualifications for Employment noted above.
Job Skills: Investigation, Critical Thinking, Collaboration, Decision Making, Attention to Detail, ConfidentialitySupplemental InformationThe Attorney General's Office is a dynamic organization that offers career opportunities across many different disciplines to people from all backgrounds and experiences. We do not discriminate in any way. All people are equal under the law, and it is so at the AGO. This is a workplace where talent gains you entry and performance determines your career path. Staff can join and lead employee resource groups and participate in online or in-person events to learn about the experiences of others. Employees of the Attorney General's Office must have been in their current positions for at least 12 months in order to be eligible for consideration.The Attorney General's Office may fill additional, similar positions as a result of this posting.The Ohio Attorney General's Office is an Equal Opportunity Employer.AGO#: 26-01-013Background Check Information:Selected candidate(s) will be subject to the following background checks:Criminal history Driving record TaxesDrug TestPolygraph TestField TestPsychological ExamPhysical ExamIn addition, an Internet search may be conducted of publicly available and job related information through social media(Facebook, LinkedIn, Twitter, etc.) or through the use of search engines (Google, Bing, etc.)
$33.1-46.6 hourly Auto-Apply 4h ago
AML Investigator
Treliant 4.2
Remote crime scene investigator job
Treliant is an essential consulting firm serving banks, mortgage originators and servicers, fintechs, and other companies providing financial services globally. We are led by practitioners from the industry and the regulatory community who bring deep domain knowledge to help our clients drive business change and address the most pressing compliance, regulatory, and operational challenges.
We provide data-driven, technology-enabled consulting, implementation, staffing, and managed services solutions to the regulatory compliance, risk, credit, financial crimes, and capital markets functions of our clients.
Founded in 2005, Treliant is headquartered in Washington, DC, with offices across the United States, Europe, and Asia.
Treliant is committed to fostering a diverse, equitable and inclusive environment that values and embraces all races, religions, ages, abilities, genders, sexual orientations, ethnicities, languages, nationalities, political parties, socioeconomic groups and other characteristics that inform an individual's worldview, experiences and system of beliefs (“the principles”). We believe in championing every voice and ensuring everyone's full potential.
Treliant is hiring experienced AML/BSA Analysts and Investigators for project-based client engagements. All work will be 100% remote.
Responsibilities
While the scope of each project may be different, your duties & responsibilities may include:
Review and independently assess cases derived from Anti-Money Laundering (AML)/Bank Secrecy Act (BSA) suspicious activity monitoring and Economic Sanctions/Office of Foreign Assets Control (OFAC) screening conducted by Treliant or client.
Review and independently assess Customer Due Diligence (CDD) and Enhanced Due Diligence (EDD) cases derived from customer profile monitoring to ensure complete and accurate Know Your Customer (KYC) profiles and Customer Identification Program (CIP) requirements.
Utilize transaction monitoring and case management systems (as available), vendor solutions, and open source tools to conduct investigations.
Compare observed activity with client KYC and expected activity profiles for potentially suspicious transactions or behaviors.
Prepare observations from review and analysis through compiling of review notes, documentation and resolution.
Interact with client compliance and operational staff, customer service areas and management in conducting reviews.
Determine whether activity should be escalated for further review based on alert reviews.
Determine whether suspicious activity reports (SARs) should be filed based on case investigations.
Manage of weekly case load in a timely fashion in accordance with Treliant's Service Level Agreement (SLA's).
Meet weekly time-keeping and reporting requirements vis-à-vis client and Treliant.
Communicate professionally, transparently, and in a timely fashion regarding weekly scheduling to client and/or Treliant Supervisors.
Qualifications
Knowledge of government regulatory requirements and expectations for identifying unusual or suspicious activity in connection with financial transactions, related to economic sanctions (e.g., OFAC), and the requirements to file suspicious activity reports.
Five (5) years of experience conducting AML/BSA and/or Economic Sanctions/OFAC investigations at financial institutions.
Strong analytical skills derived from previous experience in a Financial Intelligence Unit (FIU) or similar investigative setting including former law enforcement.
Strong written and verbal communication skills a must to work effectively with all levels of consultants and client staff.
Ability to work well with others as well as independently and with minimal supervision.
Strong organizational and time management skills and ability to handle multiple tasks/projects simultaneously.
Proficient in various software applications including Excel, Word, PowerPoint, email, banking systems and transaction monitoring/case management software (e.g., Mantas, Actimize, Fircosoft, Fiserve AML Manager, PRIME Compliance Suite).
Experience conducting and interpreting Lexis Nexis and Negative News Searches.
Experience writing SAR and alert/case narratives summarizing the results of investigations and selecting requisite supporting documentation.
Experience with historical transaction analyses (i.e., “lookbacks”) preferred, including conducting flow of funds analysis and compiling associated supporting documentation.
Prior consulting experience preferred.
Benefits
Primary Location:
Remote
Primary Location Salary Range:
$25/hr - $65/hr
Treliant offers a comprehensive, total rewards package that includes competitive compensation and a flexible benefit package that reflects our commitment to creating a diverse and supportive workplace. In addition to a competitive base salary, candidate is eligible for incentive pay as well as a full range of health benefits, vacation plan, and 401k plan.
If you want to be part of a dynamic team of professionals, we invite you to join the team at Treliant. We invest in people, and challenge you to advance your career while achieving your aspirations and goals. Here at Treliant, we pride ourselves on our collaborative team culture, where we embrace diversity of thought and innovation. If you strive for excellence and seek an inclusive environment apply on line treliant.com and follow us on LinkedIn.
Right to Work
Treliant is not in the position to provide sponsorship for this current position and so applicants must be able to work in the United States without requiring sponsorship.
Please note,
Treliant receives a high volume of applications for all roles. While we will endeavor to respond to all applicants, this is not always possible. Should you not receive a response to your application within 2 weeks, it is likely that you will have been unsuccessful on this occasion. However, we would like to retain your details on our systems and may contact you should another potentially suitable vacancy arise.
Treliant LLC is an Equal Opportunity Employer and does not discriminate on the basis of race, color, national origin, sex, sexual orientation, genetic information, religion, age, disability, or military status in employment or provision of services. When contacted for an interview, an applicant who requires special accommodations due to a disability should notify the office so that proper arrangements can be made.
$25 hourly Auto-Apply 60d+ ago
SIU Program Integrity Investigator - Remote (In Idaho)
Magellan Health 4.8
Remote crime scene investigator job
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.
$58.4k-93.5k yearly Auto-Apply 23d ago
Program Integrity Clinical Investigator (Remote-NC)
Partners Behavioral Health Management 4.3
Remote crime scene investigator job
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.
$56k-69k yearly est. Auto-Apply 15d ago
Part Time Bilingual (Spanish) Private Investigator - Special Investigations Unit (SIU)
The Robison Group 4.2
Remote crime scene investigator job
Qualified candidates are interested in utilizing their investigative skills to conduct a variety of investigations on insurance related matters; such as auto and property theft, fire damages, auto accidents, commercial claims, finding missing persons, courthouse searches, and other investigative tasks. For this position, you will also need to be fluent in writing, reading and speaking Spanish.
This is a remote opportunity for part-time employment in our Special Investigations Unit (SIU). As an SIU Investigator, you will be joining an incredible team of investigators and industry leaders.
PRINCIPAL RESPONSIBILITIES:
Complete recorded detailed interviews of those insured, claimants, witnesses, and others as identified.
Complete sceneinvestigations, including photographing.
Conduct in-person visit of medical clinics.
Complete neighborhood canvasses.
Make sound judgments during the course of the investigation.
Provide timely progress updates.
Complete detailed investigative reports.
WHO SHOULD APPLY:
Candidates with at least five (5) years of investigations experience are strongly encouraged to apply.
We are looking for people who are enthusiastic about investigations, those who thrive in a diverse work environment, and individuals who have a commitment to the very highest standards of honesty, integrity, and respect.
POSITION QUALIFICATIONS:
MUST have current and active Private Investigation License to be eligible for hire.
Self-motivated, determined, and intuitive with a strong initiative and work-ethic.
Ability to identify critical issues quickly and accurately.
Demonstrate observational, organizational, and listening skills.
Excellent oral and written communication.
Fluent in Spanish language (writing, reading, speaking).
Ability to work independently, as well as in a team.
Flexible schedule working weekends, holidays, and possible evenings.
Candidate must own a reliable computer, preferably a laptop, with access to high-speed internet and a scanner or fax machine.
Must have strong computer and internet skills.
Proficient with a digital camera.
Must possess a valid driving license and own your reliable vehicle.
Applicants must pass an extensive background check.
Must be able to pass a drug test with negative results (except when undergoing documented medical treatment).
College Degree preferred.
COMPENSATION & REIMBURSEMENTS:
Hourly Rate is commensurate with education and experience.
Paid travel time and reimbursement for mileage, tolls, and other per diem items.
READY TO APPLY?
Please submit your FULL resume, including salary requirements.