Investigator II - Fraud Operations

Who We Are

Point32Health is a leading not-for-profit health and well-being organization dedicated to delivering high-quality, affordable healthcare. Serving nearly 2 million members, Point32Health builds on the legacy of Harvard Pilgrim Health Care and Tufts Health Plan to provide access to care and empower healthier lives for everyone. Our culture revolves around being a community of care and having shared values that guide our behaviors and decisions. We’ve had a long-standing commitment to inclusion and equal healthcare access and outcomes, regardless of background; it’s at the core of who we are. We value the rich mix of backgrounds, perspectives, and experiences of all of our colleagues, which helps us to provide service with empathy and better understand and meet the needs of the communities where we serve, live, and work. 

We enjoy the important work we do every day in service to our members, partners, colleagues and communities. Learn more about who we are at Point32Health.

Job Summary

Point32Health is currently seeking highly motivated individuals to join our organization as a Fraud Operations Specialist within our Special Investigations Unit (“SIU”). The Fraud Operations Specialist is an essential team member of the SIU, responsible for developing and maintaining relationships with business units, vendors, law enforcement agencies, regulators and other parties with direct interaction with the SIU. The Sr. Fraud Operations specialist will also create and deliver anti-fraud training to internal business units.

Job Description

• Developing a deep understanding of overall plan operations to assist SIU investigative staff in obtaining information.
• Creation and delivery of annual anti-fraud training as well as tailored presentations delivered to various business units.
• Oversees the preparation and submission of SIU Independent Review Organization submissions.
• Serves as point-person for SIU regulatory and contractual audit preparation and response.
• Maintain SIU contractual and regulatory compliance including serving as the point person for SIU mandatory reporting.
• Performs annual and periodic maintenance of the SIU Policies & Procedures manual
• Represents the SIU on various internal working groups, and committees.
• Responsible for leading complex provider investigations related to fraud, waste and abuse, and developing action plans to address the investigative findings and prevent future loss.
• Perform out-of-the-box thinking, collaborate with others, and make a difference every day!
• Maintains a small investigative caseload.
• Collaborates with Point32Health Legal department and SIU Data Analytics team to provide data and documents in response to law enforcement subpoenas and requests for information.

Salary Range

$80,097.93 -$120,146.89

Compensation & Total Rewards Overview

The annual base salary range provided for this position represents a range of salaries for this role and similar roles across the organization.  The actual salary for this position will be determined by several factors, including the scope and complexity of the role; the skills, education, training, credentials, and experience of the candidate; as well as internal equity. As part of our comprehensive total rewards program, colleagues are also eligible for variable pay. Eligibility for any bonus, commission, benefits, or any other form of compensation and benefits remains in the Company's sole discretion and may be modified at the Company’s sole discretion, consistent with the law.

Point32Health offers their Colleagues a competitive and comprehensive total rewards package which currently includes:

• Medical, dental and vision coverage

• Retirement plans

• Paid time off

• Employer-paid life and disability insurance with additional buy-up coverage options

• Tuition program

• Well-being benefits

• Full suite of benefits to support career development, individual & family health, and financial health

For more details on our total rewards programs, visit https://www.point32health.org/careers/benefits/

We welcome all
All applicants are welcome and will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.

Scam Alert: Point32Health has recently become aware of job posting scams where unauthorized individuals posing as Point32Health recruiters have placed job advertisements and reached out to potential candidates. These advertisements or individuals may ask the applicant to make a payment. Point32Health would never ask an applicant to make a payment related to a job application or job offer, or to pay for workplace equipment. If you have any concerns about the legitimacy of a job posting or recruiting contact, you may contact [email protected]