Senior SIU Investigator

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

📋 Description

• Take the initiative to lead intricate investigations concerning fraud, waste, and abuse involving providers, members, pharmacies, vendors, and other entities.

• Utilize referrals, claims data, medical records, interviews, analytics, and various investigative resources to construct cases.

• Examine complex claims, billing trends, medical records, provider documentation, financial data, and other forms of evidence.

• Formulate investigative strategies, define the direction of cases, and oversee investigations until resolution.

• Create investigative reports, referrals, case summaries, presentations, and necessary supporting documentation.

• Offer subject matter expertise to investigative personnel on techniques, case development, documentation, evidence, and regulations.

• Work in collaboration with Compliance, Legal, Payment Integrity, Provider Relations, government agencies, and law enforcement partners.

• Spot emerging fraud schemes, billing inconsistencies, control gaps, and risks to program integrity.

• Suggest enhancements to investigative processes, monitoring activities, and analytical methods.

• Assist in audits, identify and recover overpayments, respond to regulatory requests, support special projects, enterprise initiatives, and handle complex investigative issues.

• Ensure investigations adhere to quality, timeliness, documentation, service-level, and regulatory standards.

• Contribute to training, knowledge sharing, and continuous improvement efforts.

• Facilitate case advancement through onsite audits, visits, drive-by activities, and interviews with members, providers, and witnesses.

• Perform other assigned tasks and adhere to policies and standards.

⛳️ Requirements

• A Bachelor's Degree in Business, Criminal Justice, Healthcare Administration, Public Health, or a related field, or equivalent experience is required.

• A minimum of 4 years in conducting fraud, waste, and abuse investigations, healthcare fraud investigations, claims audits, payment integrity reviews, healthcare compliance investigations, law enforcement investigations, or similar investigative roles is required.

• Proven experience in leading complex investigations that involve multiple data sources, extensive analysis, and coordination with internal and external stakeholders.

• Experience in preparing investigative reports, referrals, presentations, and supporting documentation for leadership, regulatory agencies, and law enforcement entities.

• Ability to understand and apply federal and state healthcare regulations, including those related to Medicaid, Medicare, and other government-sponsored healthcare programs is preferred.

• Additional qualifications may be necessary to meet applicable federal, state, regulatory, contractual, or program-specific requirements.

• Certifications such as AHFI, CFE, CPC, CPMA, or other related investigative, auditing, or compliance certifications are preferred.

• Capability to conduct onsite audits, visits, drive-by activities, and interviews.

• A Master's Degree is preferred.

🏝️ Benefits

• Competitive pay

• Health insurance

• 401K plan

• Stock purchase plans

• Tuition reimbursement

• Paid time off plus holidays

• Flexible work arrangements including remote, hybrid, field, or office schedules

• Additional forms of incentives may be included in total compensation