A Claims Investigator investigates and assesses insurance claims to verify the validity of insurance claims. Determines the level of liability and determines pay-out amounts. Prepares evaluation reports to document the evidence to be used in court.
Medi Trans, LLC Position Summary The Fraud, Waste and Abuse (FWA) Specialist is responsible for supporting Medi Trans, LLC's efforts to identify, prevent, investigate, and report suspected fraud, waste, and abuse within the Non-Emergency Medical Transportation (NEMT) program. This position will review transportation records, claims, trip activity, provider documentation, member information, and other available data to identify unusual or potentially inappropriate activity. The FWA Specialist will conduct investigations, document findings, communicate with internal departments and transportation providers, and assist with corrective actions and recovery efforts when appropriate. The ideal candidate will have strong analytical and investigative skills, excellent attention to detail, sound judgment, and the ability to handle confidential and sensitive information. Essential Functions Review transportation trips, claims, billing records, and supporting documentation for potential fraud, waste, and abuse. Conduct preliminary and detailed investigations of suspected FWA activity. Identify unusual billing patterns, trip activity, provider behavior, member activity, or other potential compliance concerns. Review provider records for discrepancies, duplicate billing, inappropriate trips, excessive utilization, falsified documentation, or other irregularities. Investigate potential transportation provider overpayments and assist with recovery efforts. Review member and provider complaints involving potential FWA concerns. Compare trip records, authorization information, provider documentation, call records, GPS information, and other available data as part of investigations. Conduct interviews or fact-finding activities with employees, transportation providers, members, or other appropriate parties when necessary. Contact transportation providers to obtain clarification or supporting documentation. Work with Operations, Claims, Credentialing, Provider Network, Quality Assurance, and other departments during investigations. Maintain detailed and accurate investigation files and case documentation. Document investigative findings, supporting evidence, actions taken, and outcomes. Escalate significant or high-risk findings to the FWA Supervisor or appropriate leadership. Assist with identifying trends and recurring issues that may indicate systemic FWA concerns. Assist with developing recommendations for corrective action and process improvements. Monitor corrective actions and follow up on outstanding documentation or responses. Assist with provider education and communication regarding FWA requirements and expectations. Maintain confidentiality of all member, provider, employee, and investigation information. Ensure investigations are conducted consistently with MediTrans policies, contractual requirements, and applicable laws and regulations. Assist with audits, compliance reviews, and requests for information from health plans, regulatory agencies, or other authorized entities. Prepare reports, spreadsheets, summaries, and other documentation related to FWA activities. Maintain accurate case tracking and investigation logs. Meet established deadlines for investigations, documentation, reporting, and follow-up activities. Perform other compliance, FWA, and investigative duties as assigned. Key Areas of Investigation The FWA Specialist may investigate concerns involving: Duplicate or inappropriate billing Trips that did not occur Transportation services not supported by documentation Inappropriate or excessive trip utilization Provider overpayments Falsified or altered transportation records Unauthorized transportation services Improper trip modifications Inappropriate provider billing practices Member/provider collusion Identity or eligibility concerns Transportation provider credentialing concerns Potential kickbacks or inappropriate financial arrangements Misuse of transportation benefits Other suspected fraud, waste, or abuse QualificationsRequired High school diploma or equivalent. 1-2 years of experience in compliance, investigations, healthcare, insurance, claims, auditing, customer service, or a related field preferred. Strong analytical and problem-solving skills. Excellent attention to detail. Strong written and verbal communication skills. Ability to review large amounts of information and identify discrepancies or unusual activity. Strong organizational and time-management skills. Ability to maintain confidentiality. Ability to exercise sound judgment and make appropriate recommendations. Proficiency with Microsoft Office, particularly Excel and Word. Ability to work independently and manage multiple investigations and priorities. Preferred Associate or bachelor's degree in Criminal Justice, Business Administration, Healthcare Administration, Compliance, Accounting, or a related field. Previous Fraud, Waste & Abuse experience. Healthcare, Medicaid, insurance, claims, or NEMT experience. Experience conducting investigations or audits. Experience identifying provider overpayments. Experience with data analysis and investigative software. Knowledge of Medicaid program requirements and healthcare compliance. Compliance certification or fraud-related certification is a plus. Knowledge, Skills, and Abilities Ability to analyze records and identify inconsistencies or patterns. Strong investigative and fact-finding skills. Strong written documentation skills. Ability to objectively evaluate information and evidence. Ability to distinguish between legitimate errors and potential FWA concerns. Strong interviewing and communication skills. Ability to maintain professional relationships while conducting investigations. Ability to handle sensitive and confidential information. Ability to work with minimal supervision. Ability to meet deadlines and manage multiple cases simultaneously. Strong ethical standards and commitment to integrity. Ability to communicate findings clearly to management. Performance Expectations The FWA Specialist is expected to: Complete assigned investigations accurately and within established timeframes. Maintain thorough and organized case documentation. Identify potential FWA trends and escalate concerns appropriately. Support recovery of confirmed provider overpayments when applicable. Maintain confidentiality throughout all investigations. Provide objective, fact-based investigative findings. Follow MediTrans policies, procedures, and compliance requirements. Demonstrate professionalism, integrity, and sound judgment. Work collaboratively with internal departments and external partners. Confidentiality The FWA Specialist will have access to confidential member, provider, employee, claims, financial, and investigative information. All information must be handled in accordance with MediTrans policies, contractual requirements, and applicable privacy and confidentiality laws. Physical Requirements Ability to sit and work at a computer for extended periods. Ability to review electronic and written records for extended periods. Ability to communicate effectively by telephone, email, and in person. Ability to attend meetings, audits, and provider-related activities as needed. Ability to perform the essential functions of the position with or without reasonable accommodation. Equal Employment Opportunity MediTrans, LLC is committed to providing equal employment opportunities to all qualified individuals. Employment decisions are based on qualifications, business needs, and other legitimate factors without regard to characteristics protected by applicable federal, state, or local law.
Disclaimer:
This job description is intended to describe the general nature and level of work performed by employees in this position. It is not intended to be an exhaustive list of all responsibilities, duties, or qualifications required for the position. Duties and responsibilities may be modified as business needs change.
Pay:
$17.00 - $18.00 per hour
Benefits:
401(k) 401(k) matching Dental insurance Health insurance Opportunities for advancement Paid time off Vision insurance
