Investigator, Program Integrity Unit

Job Description

It’s Time For A Change...

Your Future Evolves Here

Evolent Health has a bold mission to change the health of the nation by changing the way health care is delivered. We bring our whole selves to work, and we’re driven to make a difference every day, from the work we do in our roles to the charitable endeavors we support. We believe in starting by listening, communicating with candor, fostering inclusion, and owning the opportunity. We respect and celebrate individual talents and team wins. Whether we’re wearing scrubs, jeans, or our finest work-from-home chic, we have fun, work hard, and make time to help others.

Are we growing? Absolutely. We have seen about 30% average growth over the last three years. Are we recognized? Definitely. We were named one of “Becker’s 150 Great Places to Work in Healthcare” in 2016, 2017, 2018 and 2019 and are proud to be recognized as a leader in driving diversity, equity, and inclusion (DE&I) efforts. Evolent achieved a 100% score on the 2020 Human Rights Campaign's Corporate Equality Index, making us one of the best places to work for LGBTQ+ employees. We were also named on the Best Companies for Women to Advance List 2020 by Parity.org and we publish an annual Diversity Report to share our progress on how we’re building an equitable workplace and performing on various metrics. If you’re looking for a place where your work can be personally and professionally rewarding, don’t just join a company with a mission. Join a mission with a company behind it.

Who You’ll Be Working With:

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

This individual will work as part of the Program Integrity Unit 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.

What You’ll Be Doing:

• 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
• Working with subcontractor Special Investigations unit representatives during on-going investigations
• Maintaining confidentiality of all sensitive investigative/audit information
• Performing other duties and projects as assigned

The Experience You’ll Need (Required):

• 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

Finishing Touches (Preferred):

• Bachelor’s degree
• 3-5 years of experience in fraud, waste and abuse investigating in a healthcare operation
• Knowledge of healthcare services coding and claims billing
• Knowledge of Health Insurance, Managed Care, Benefit Design, and Federal Regulations
• AHFI, CFE, and/or Certified Coder with either CPC, CCS or CMPA (*Certified Professional Coder, Certified Coding Specialist, Certified Professional Medical Auditor)

Technical requirements:

Currently, Evolent employees work remotely temporarily due to COVID-19. As such, we require that all employees have the following technical capability at their home: High speed internet over 10 MBPS and, specifically for all call center employees, the ability to plug in directly to the home internet router. These at-home technical requirements are subject to change with any scheduled re-opening of our office locations.

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.