Senior SIU Investigator – CPC Required

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

📋 Description

• Oversee and take responsibility for investigations related to fraud, waste, and abuse.

• Develop and deliver findings from investigations.

• Execute analytical and process management tasks independently.

• Act as a corporate expert on issues concerning fraud, waste, and abuse.

• Suggest cost containment initiatives aimed at fraud prevention.

• Organize, prioritize, and manage workloads to fulfill performance, regulatory, and contractual obligations.

• Craft investigative work plans and strategies for cases.

• Analyze data and select audit samples through various methodologies.

• Plan and carry out desk audits, field audits, and site assessments.

• Review information related to providers, members, contracts, payment policies, and Medicaid/Medicare.

• Investigate medical policies, practices, provider attributes, and related subjects.

• Conduct interviews with patients, providers, staff, witnesses, and specialists.

• Draft correspondence and secure evidence.

• Maintain detailed case files.

• Triage leads and spot suspicious patterns in claims and provider enrollment data.

• Monitor fraud cases, schemes, investigative methods, and industry developments.

• Prepare summaries, conclusions, recommendations, and reports from investigations.

• Identify, communicate, and recover losses.

• Present cases to internal teams, law enforcement, and regulatory bodies.

• Assist in legal proceedings, including court testimony and preparation for civil or criminal cases.

• Negotiate and manage settlement agreements.

• Deliver presentations to customers, prospects, conference attendees, and law enforcement.

• Collaborate with clients regarding the status and direction of assignments.

• Build and maintain relationships with law enforcement, regulators, task forces, SIU staff, and external contacts.

• Train and mentor SIU investigators.

• Recommend and implement procedures, process flows, and industry best practices.

• Represent clients at task force and regulatory meetings.

• Measure and report on performance metrics.

• Suggest opportunities to reduce exposure to fraud, waste, and abuse.

• Develop policies and procedures aimed at combating fraud.

• Carry out other assigned responsibilities.

⛳️ Requirements

• At least 7 years of experience in fraud investigations or relevant behavioral/medical healthcare insurance roles in claims, clinical, auditing, compliance, provider networks, management, or project planning.

• Proven capabilities in time management and prioritization.

• Excellent listening and observational skills.

• Outstanding work ethic, complete reliability, and proactive problem-solving skills.

• Demonstrated ability to handle fraud and abuse cases with discretion, confidentiality, and professionalism.

• Proven strategic and analytical thinking abilities.

• Capacity to effectively communicate conclusions and recommendations to management.

• In-depth, practical knowledge of complex and diverse fraud investigative methods and techniques used in program audits.

• Familiarity with insurance terminology and policy interpretation.

• Ability to work under tight deadlines.

• Capability to work independently and collaborate with colleagues and clients.

• Proficient in managing and prioritizing caseloads with minimal supervision.

• Strong computer skills, including Microsoft Excel, Access, Outlook, Word, and PowerPoint.

• Bachelor's degree required; a combination of education and work experience may be considered.

• CPC (Certified Professional Coder) certification required for the position.

• Preferred certifications include AHFI, CFE, CPC, LSSBB, and RN state and/or compact state licensure.

🏝️ Benefits

• Potential availability of short-term incentives.

• Comprehensive benefits package.

• Health insurance benefits.

• Life insurance benefits.

• Optional voluntary benefits.

• Perks for physical, mental, emotional, and financial wellbeing.

• Tobacco-free workplace.