Lead SIU Investigator

This is a fully remote position, open to applicants in Arizona, +4 more states.

📋 Description

• Serves as a subject matter expert in Special Investigations Unit (SIU) inquiries.

• Offers direction and support to staff involved in investigating and resolving compliance issues, as well as fraud, waste, and abuse cases.

• Aids the manager in overseeing team caseloads and reporting on performance metrics.

• Guides team members in investigating and addressing compliance and fraud, waste, and abuse issues.

• Assists management in tracking team caseloads and generating metrics reports.

• Identifies training requirements and develops training materials and procedural steps.

• Delivers training and mentorship to the team regarding casework and other SIU functions.

• Evaluates and assesses allegations to determine compliance with federal and state regulations, Centers for Medicare & Medicaid Services (“CMS”) guidelines, and internal policies, procedures, and standards.

• Conducts and documents interviews for investigative purposes.

• Reviews investigative interviews conducted by junior investigators.

• Manages caseloads of moderate to high complexity, creating investigative plans for multiple cases, prioritizing, and effectively executing them.

• Thoroughly documents actions taken, organizes, and reviews case files.

• Consults with management, in-house legal counsel, and/or senior leadership to address complex issues.

• Identifies risks and recommends and communicates corrective actions to mitigate potential future risks.

• Conducts follow-ups to ensure that remedial and disciplinary actions are implemented properly and promptly.

• Prepares clear and concise investigative plans and reports.

• Provides support and guidance to junior investigative personnel.

• Identifies trends and unusual activities to create proactive leads for investigations, analyzing data to uncover potentially fraudulent actions.

• Attends, actively engages in, and/or leads meetings with managers from various business areas.

• Communicates directly with federal or state regulatory bodies.

• Prepares cases for referral to management, government entities, and law enforcement agencies.

• Cultivates and maintains strong working relationships with colleagues and regulators.

• Testifies in both criminal and civil proceedings.

• Participates in and leads special projects as required.

• Performs additional duties as assigned.

• Adheres to all policies and standards.

⛳️ Requirements

• Bachelor's Degree in a related field; or an Associate's degree with 6 years of relevant experience; or a High School Diploma/GED with 7 years of relevant experience.

• At least 5 years of experience in healthcare fraud-related investigations, including audit and risk analysis.

• Minimum of 1 year in managed care or experience with a health insurance company.

• Comprehensive knowledge of government programs, the managed care sector, Medicare, Medicaid laws and requirements, and federal, state, civil, and criminal statutes.

• Ability to read, analyze, and interpret state and federal laws, rules, and regulations.

• Familiarity with community, state, and federal laws and resources.

• Preferred knowledge and understanding of managed care claims processing systems and medical claims coding.

🏝️ Benefits

• Competitive salary.

• Health insurance coverage.

• 401K and stock purchase programs.

• Tuition reimbursement opportunities.

• Paid time off along with holidays.

• Flexible work options including remote, hybrid, field, or office schedules.