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SIU Investigator

Wellcare - Tampa, FL

SIU Investigator','1705365','!*!About WellCare: WellCare Health Plans, Inc. is a Fortune 500 company traded on the New York Stock Exchange (symbol: WCG). It provides managed care services targeted to government-sponsored health care programs, including Medicaid, Medicare, Prescription Drug Plans and the Health Insurance Marketplace. Headquartered in Tampa, Fla., WellCare offers a variety of health plans for families, children, and the aged, blind and disabled. The company serves approximately 4 million members and employs approximately 6,500 people nationwide as of Sept. 30, 2014. For more information about WellCare, please visit our website at or view our videos at All qualified applicants shall receive consideration for employment without regard to race, color, religion, sex, age forty (40) and over, disability, veteran status, or national origin.','!*!The Investigator conducts healthcare fraud and abuse investigations as a member of the Special Investigations unit within the Corporate Compliance department. Essential Functions:

Manages large caseloads and investigates allegations and issues pertaining to potential health care fraud by providers or members.

Documents investigations, including preliminary and final case reports, for both internal tracking and regulatory reporting purposes.

Proactively identifies trends and aberrant activity to generate leads for fraud investigations and analyzes claims data to detect fraudulent activity.

Supports senior compliance staff and legal counsel in all phases of investigation and litigation.

Prepares cases for referral to government agency and law enforcement.

Develops and maintains strong working relationships with associates and regulators.

Testify in criminal and civil matters as needed.

Conducts special assignments as needed.

Trains associates regarding the activities of the Special Investigation Unit.

Perform other duties as assigned. Additional Responsibilities:

','!*!Candidate Education:

Required A Bachelor's Degree in a related field or equivalent combination of education and experience Candidate Experience:

Required 3 years of experience in Investigations, preferably health care fraud-related investigations or

Required 3 years of experience in healtcare involving investigatory-type analytic skills combined with a strong desire to develop additional investigatory skills.

Preferred 3 years of experience in Pharmacy Investigators - Pharmacy PBM and/or claims experience Candidate Skills:

Intermediate Other In-depth knowledge of government programs, the managed care industry, Medicare, Medicate laws and requirements, federal, state, civil and criminal statutes.

Intermediate Ability to work in a fast paced environment with changing priorities

Intermediate Demonstrated organizational skills

Intermediate Ability to multi-task

Intermediate Demonstrated written communication skills Licenses and Certifications:A license in one of the following is required:

Preferred Other Accredited Health Care Fraud Investigator (AHFI) or Certified Fraud Examiner (CFE)

Preferred Other Pharmacy Investigator - Certified Pharmacy Technician Technical Skills:

Preferred Intermediate Other Knowledge and understanding of claims processing systems and medical claims coding preferred

Preferred Intermediate Other Computer literate (MS Office, Excel, etc.) Languages:

','US-FL-Tampa','8735 Henderson Rd','','Tampa','33634','','','No','No','SIU Investigator'

10 days 10 hours ago



SIU Investigator Wellcare - Tampa, FL, United States


Location: Tampa, FL

Company Profile:
WellCare Health Plans, Inc. focuses exclusively on providing government-sponsored managed care services, primarily through Medicaid, Medicare Advantage and Medicare Prescription Drug Plans, to families, children, seniors and individuals with complex medical needs. The company served approximately 3.8 million members nationwide as of Sept. 30, 2015. For more information about WellCare, please review our website and view the company’s videos. WellCare has developed a full complement of expertise in three major areas of government-sponsored health care…. Medicaid, Medicare Advantage and Medicare Prescription Drug Plans. Leveraging our expertise for our members' benefit is a key part of the value we bring to our members. WellCare focuses on those members who are dually eligible for both Medicaid and Medicare. This is an area of specialization that many other health plans simply do not have. We are committed to continually improving the quality of care and service that we provide to our members. We help our members access the right care at the right time in the appropriate setting. For some members, this includes the use of coordinated care teams and community partnerships. And we’re focused on government customers and use a disciplined approach to ensure a competitive cost structure.