**Job Description:**

Select Health is a not-for-profit community health plan serving more than 1 million members in the Intermountain west. Select Health’s line of businesses (LOB) includes Medicare, Medicaid, FEHB, Marketplace Qualified Health Plans and fully funded and self-funded Commercial plan. An Investigator in the Special Investigations Unit at Select Health receives and investigates allegations of Fraud Waste and Abuse (FWA) by gathering evidence through data analytics, records reviews, investigative interviews or by many other means, then presents findings in writing and orally to Select Health senior leadership as well as law enforcement agencies. This position is directly responsible for helping to protect billions of premium dollars used to pay claims, ensuring claims are paid appropriately and accurately.

**This role is remote the candidate must be able to work remotely and be okay to have virtual interactions with the team via teams. including on camera meetings and have a room that is isolated from outside traffic with a professional background.**

**We are committed to offering flexible work options where approved and stated in the job posting. However, we are currently not considering candidates who reside or plan to reside in the following states: California, Connecticut, Hawaii, Illinois, New York, Rhode Island, Vermont, and Washington.**

**Essential Functions**

+ Receives referrals through various sources and investigates potential Fraud Waste and Abuse allegations, seeking evidence by means of data analytics, records reviews, investigative interviews, surveillance, onsite audits and many other methods.

+ Presents investigative findings to executive leadership along with recommended corrective action plans to implement with subjects of investigations. These plans can vary greatly but often include provider education, overpayment collection, contract terminations and fraud referrals to law enforcement and other regulators.

+ Prepares detailed investigative reports for local and federal law enforcement agencies as well as for other regulatory agencies.

+ Assists local and federal law enforcement agencies or other regulators in supporting investigative efforts where Select Health may have exposure to the Fraud Waste or Abuse being investigated. This may be anything from sharing investigative findings, sharing industry knowledge up to and including testifying in court to work performed on specific investigations.

+ Ensures all regulatory and contract requirements are met in regard to work done in the Special Investigations Unit. Also assists in audit preparation and interviews when regulators or the Intermountain Internal Audit team audits Select Health’s Fraud Waste and Abuse program.

+ Prepare and present Fraud Waste and Abuse awareness training for new customer service agents, other departments within Select Health and Intermountain and at seminars and conferences.

+ Builds and maintains strong working relationships with other departments within Select Health critical to the success of the Special Investigations Unit. This position will also build and maintain these same working relationships with other insurance companies’ Special Investigations Units as well as Law Enforcement Agencies within the Select Health service area.

**Skills**

+ Analytical Thinking

+ Interpersonal Communication

+ Investigative Interviewing

+ Computer Literacy

+ Criminal Justice

+ Legal

+ Project Management

+ Insurance Fraud

+ Law Enforcement

+ Accounting

**Qualifications**

Minimum Qualifications

Eight years of professional experience in medical insurance, insurance fraud, law enforcement or related field. College degrees can also be counted towards years of professional experience when obtained through an accredited institution and is verified

Experience requiring effective problem-solving, critical thinking, process analysis, and other strong analytical skills.

Experience in managing or planning work assignments that require strong interpersonal and organizational skills and managing time effectively with minimum supervision.

Demonstrated collaboration, team-orientation, and initiative skills.

Demonstrated ability to interact professionally with mid– to upper-level management of clinics, pharmacies or other organizations.

Demonstrated ability to work independently, adapt to change quickly, deal with ambiguity, and multi-task.

Demonstrated proficiency in word processing and spreadsheets.

Ability to travel when necessary to attend educational opportunities such as conferences and seminars, to attend taskforce meetings or to conduct onsite audits and interviews to support investigations. Occasionally, travel will involve overnight stays.

Preferred Qualifications

Bachelor’s Degree in related field such as Business, Computer Science or Criminal Justice. Degree must be obtained through an accredited institution and is verified.

Certified Health Care Professional

Experience investigating, interviewing and working with law enforcement

Database querying skills, specifically using Standard Query Language (SQL)

Ability to proactively identify fraud schemes or anomalies in billing trends through data analytics

Health care and/or Health Insurance industry knowledge of medical and/or pharmacy claims, payment policies and terminology

Knowledge of federal and state fraud statutes including but not limited to mandatory reporting statutes, False Claims Act, Stark Laws, Anti-Kickback Statutes etc

Excellent problem solving, negotiation, and process improvement skills.

**Physical Requirements**

+ Ongoing need for employees to see and read information, documents, monitors, identify equipment and supplies, and be able to assess customer needs.

+ Frequent interactions with colleagues and providers require employee to verbally communicate as well as hear and understand spoken information, needs, and issues quickly and accurately.

+ Manual dexterity of hands and fingers to manipulate complex and delicate equipment with precision and accuracy. This includes frequent computer use for typing, accessing needed information, etc.

**Physical Requirements:**

**Location:**

SelectHealth - Murray

**Work City:**

Murray

**Work State:**

Utah

**Scheduled Weekly Hours:**

40

The hourly range for this position is listed below. Actual hourly rate dependent upon experience.

$30.55 - $48.12

We care about your well-being – mind, body, and spirit – which is why we provide our caregivers a generous benefits package that covers a wide range of programs to foster a sustainable culture of wellness that encompasses living healthy, happy, secure, connected, and engaged.

Learn more about our comprehensive benefits package here (https://intermountainhealthcare.org/careers/benefits) .

Intermountain Health is an equal opportunity employer. Qualified applicants will receive consideration for employment without regard to race, color, religion, age, sex, sexual orientation, gender identity, national origin, disability or protected veteran status.

At Intermountain Health, we use the artificial intelligence ("AI") platform, HiredScore to improve your job application experience. HiredScore helps match your skills and experiences to the best jobs for you. While HiredScore assists in reviewing applications, all final decisions are made by Intermountain personnel to ensure fairness. We protect your privacy and follow strict data protection rules. Your information is safe and used only for recruitment. Thank you for considering a career with us and experiencing our AI-enhanced recruitment process.

All positions subject to close without notice.