Senior Investigator, Special Investigations Unit – SIU

This is a fully remote position, open to applicants in Oklahoma.

📋 Description

• Perform in-depth, sophisticated investigations into suspected healthcare fraud and abuse.

• Examine program-integrity issues related to irregular Medicaid claims.

• Conduct research on subjects and associated entities.

• Independently carry out proactive data mining utilizing SIU tools.

• Analyze claims data to uncover irregularities, trends, and schemes.

• Research and prepare documentation for clinical and legal evaluations.

• Collaborate with Medical Directors regarding clinical matters and medical-record inquiries.

• Record case activities and communications in the specified tracking system.

• Relay clinical findings to healthcare providers.

• Comply with regulatory standards.

• Aid in the recovery of company and customer funds lost due to improper billing.

• Mentor and provide guidance to new and junior investigators.

• Assist junior investigators in accessing resources and formulating investigative strategies.

• Serve as a backup to the Team Leader when necessary.

• Work together with federal, state, and local law enforcement agencies on healthcare-fraud investigations and prosecutions.

• Present findings related to healthcare fraud and FWA knowledge to both internal and external stakeholders.

• Provide testimony in civil and criminal court cases.

• Create professional presentations addressing healthcare fraud issues and enterprise FWA strategies.

• Suggest improvements in efficiency and contribute to the development of FWA monitoring controls.

⛳️ Requirements

• Must be a resident of Oklahoma.

• 2-5 years of investigative experience in healthcare fraud and abuse.

• Working knowledge of medical coding, including CPT, HCPCS, and ICD10.

• Proficient in Microsoft Office applications.

• Advanced skills in Excel, including the use of pivot tables.

• Experience with Power BI.

• Self-motivated individual who takes the initiative in research essential to investigations.

• Skilled in sourcing information and identifying new case resources.

• Willingness to travel up to 10%.

• Preferred experience in Medicaid/Medicare investigations.

• Familiarity with relevant Medicaid/Medicare rules and regulations is preferred.

• Preferred credentials include Association of Certified Fraud Examiners (CFE) or National Health Care Anti-Fraud Association (AHFI).

• Preferred knowledge and understanding of complex clinical issues.

• Excellent verbal and written communication skills.

• Strong analytical skills to evaluate claims data from various perspectives.

• Bachelor’s degree or equivalent experience (5+ years in healthcare fraud, waste, and abuse investigations).

🏝️ Benefits

• Medical coverage.

• Dental coverage.

• Vision coverage.

• Paid time off.

• Retirement savings options.

• Wellness programs.

• Additional resources to support physical, emotional, and financial well-being.

• CVS Health bonus, commission, or short-term incentive programs in addition to base salary.