Investigative Support Specialist

Bring your drive for excellence, team orientation, and customer commitment to Independence; help us renew and reimagine our business and shape the future of health care.  Our organization is looking to diversify, grow, innovate, and serve, and we are seeking an Investigative Support Specialist

Independence’s Corporate and Financial Investigations Department (CFID) safeguards the integrity and assets of Independence affiliates and customers by identifying, preventing, and reporting potential fraud, waste, and abuse (FWA) in medical and pharmacy utilization, as required by regulators, including CMS.

The CFID Support Team investigates allegations of FWA, which may involve requesting medical records, retracting claims, seeking repayments, or referring cases to the Investigative Unit. The team also performs proactive data analysis to identify entities for audit or investigation.

Key Responsibilities:

• Research and resolve FWA allegations by reviewing claims and medical records for compliance with plan guidelines.
• Initiate claim retractions or corrections for billing/coding errors; escalate suspected fraud to Investigations.
• Handle Medicare-related allegations and report outcomes to MAG for subscriber notifications.
• Independently decide on claim adjustments, repayments, and referrals.
• Collaborate with senior analysts on proactive reviews, trend analysis, and provider audits.
• Utilize tools (Informant, Fraud Shield, INSINQ) to monitor claims, flag members, and analyze provider patterns.
• Manage recovery processes for overpayments and ensure accurate financial reporting.
• Monitor flagged accounts for potentially fraudulent activity for 90 days.

QUALIFICATIONS:

• 3-5 years of relevant experience. 

• High School degree or equivalent.

• Working toward a Certification in Fraud Analysis is preferred.

• Has in-depth knowledge in own discipline and extensive knowledge of related disciplines such as claims payment system, benefit analysis, medical policy, and provider contracts.

• Based on analysis and research, initiates claim offsets, retractions, and demand letters for provider repayment agreements.

• Solves complex problems; takes a new perspective on existing solutions such as claims payment edit updates, medical policy change, and provider contract/third party issues. 

• Works independently; receives minimal to no guidance.  Acts as a resource for colleagues with less experience and peers