Investigator, Program Integrity Unit at Evolent Health

Evolent Health


Entry Level


Not defined

09 Jul → 08 Aug

Job Description

Evolent Health is looking for an Investigator to be a key member of the Program Integrity Unit within the Compliance Department.

This individual will work to assist in executing Evolent Health’s mission by ensuring that Evolent maintains an effective compliance program which includes measures to prevent, detect and correct fraud, waste, and abuse.

Evolent Health is an equal opportunity employer and considers all qualified applicants equally without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran status, or disability status. Evolent Health maintains a drug-free workplace.

Job Responsibilities

  • Performing target claim audits (desk and on-site) as directed; distributing audit reports by the required due date
  • Conducting investigations, including but not limited to, data analysis, record review, provider office inspections, and field observations
  • Communicating audit findings internally to the Special Investigations Unit, executive leadership and state or federal regulatory entities as needed
  • Serving as an integral attendee and contributor at Special Investigations Unit meetings
  • Gathering and reviewing data in response to inquiries sent to the Special Investigations Unit
  • Handling Fraud, Waste, and Abuse (FWA) hotline calls and e-mails, responding to messages received and tracking receipt of calls and e-mails
  • Assisting in development and implementation of FWA policies and procedures
  • Maintaining up-to-date notes and documentation on respective case load in the Investigation Database
  • Assisting in planning, development, and delivery of FWA related educational training for the company and providers
  • Acting as the Special Investigations Unit Liaison to assigned company departments to provide educational information and soliciting feedback
  • Maintaining confidentiality of all sensitive investigative/audit information
  • Performing other duties and projects as assigned

Requirements / Qualifications

  • 1-2 years of experience in FWA investigating in a healthcare operation

  • Knowledge of corporate investigative practices

  • Proficient understanding of medical terminology, human anatomy, medical tests and procedures, and health conditions

  • Leadership skills to effectively communicate with staff and regulatory representatives

  • Investigative, decision-making, problem solving, interpersonal and organizational skills

  • Consistent demonstration of accuracy, thoroughness, and timeliness in completing work assignments; detail-oriented

  • Excellent ability to plan, organize and maintain multiple projects and files

  • Excellent verbal and written communication skills and interpersonal skills

  • Proficient experience using Outlook, Word, Excel, and PowerPoint in a Windows operating system

  • Ability to adapt to fluctuating situations

  • 3-5 years of experience in fraud, waste and abuse investigating in a healthcare operation (Preferred)

  • Knowledge of healthcare services coding and claims billing

  • AHFI, CFE, and/or Certified Coder with either CPC, CCS or CMPA (*Certified Professional Coder, Certified Coding Specialist, Certified Professional Medical Auditor)

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