Job overview

This position is responsible for conducting objective, fair, thorough, unbiased, and timely investigations of healthcare fraud and abuse committed against Allianz group or its payers by members, providers, or other entities whilst monitoring best of relationships with all parties.

The position requires ingenuity and creativity to obtain case information not readily available, along with the ability to work independently with minimum supervision. Good organizational skills are needed to manage a high volume of assigned cases as well as the regular exercise of independent judgment and initiative to investigate allegations.

The investigator must have the analytical ability necessary to review, interpret, and evaluate relevant information essential in resolving sensitive and complex investigations.

What you will do

• Data mining and data analysis for providers under investigations
• Participate in onsite audits, in-house claims audit, offsite audits with data trending and mystery shopping campaigns
• Review files, gather information, collect evidence to detect fraud and abuse on claims
• Drive savings and cost containment strategies
• Assess the scope and determine the methodology needed to carry out an efficient investigation
• Document all evidence obtained in the investigation in order to substantiate meritorious claims, to deny unjustified claims, to recover inappropriate payments, or to recommend action against responsible parties
• Support the medical provider performance manager with all administration and support tasks to drive provider performance monitoring
• Support and drive the savings target strategy as set by the global head of MPM
• Collaborate and communicate internally with associated departments, i.e., legal, finance, claims operations, as well as external clients and providers
• Consult with legal and regulatory authorities for cases that may involve legal action
• Manage and ensure generation of periodic dashboards
• Participate in specialized projects and assignments related to procurement, as required
• Maintain provider relationships in coordination with MPM team
• Use judgment, diplomacy, and confidentiality with respect to the complete procurement process, ensuring integrity
• Preserve the reputation of company, beneficiaries, payers, and all other parties involved
• AI readiness - work effectively in an environment shaped by artificial intelligence (AI), machine learning, data, analytics, and cloud-based tools, using insights responsibly with our standards of data governance, security, and ethical use

What you will need

• Expertise in general industry trends
• A thorough knowledge of the various types of insurance fraud and the strategies and techniques used in their investigation and of federal and state regulations
• Strong interpersonal and relationship skills
• Excellent written and verbal communication skills used for interviewing and corresponding with claimants, attorneys, doctors, law enforcement, etc.
• A high degree of integrity, dependability, accountability, and confidentiality is required for handling information that is considered personal and confidential
• Ability to analyze data and interpret results
• Ability to adapt, meet the changing demands of work environment, any delays or other unexpected demands
• Ability to treat people with respect under all circumstances, instill trust in others besides upholding the values of organization
• Ability to collaborate and work with internal and external colleagues to successfully complete the defined tasks and provide superior customer service

How we hire

Allianz Partners does not accept unsolicited CVs or approaches from agencies. We only work with partners on our approved supplier lists, under contract. Any unsolicited submission will not be considered.