SIU Investigator

This is a fully remote position, open to applicants in Arizona, +12 more states.

📋 Description

• Conduct investigations into fraud, waste, and abuse utilizing referrals, claims data, medical records, interviews, data analytics, and various investigative tools.

• Analyze, document, and maintain records of investigative activities, findings, recommendations, and outcomes.

• Review claims, medical records, provider billing practices, enrollment details, financial documents, and other pertinent information to uncover fraud, waste, abuse, overpayments, or compliance issues.

• Prepare investigative reports, case summaries, referrals, and supporting documentation for internal stakeholders, regulatory bodies, law enforcement agencies, and other authorized entities.

• Collaborate with internal business partners, compliance, legal teams, provider and payment integrity teams, as well as external agencies.

• Assist in corrective measures, recoveries, case resolution efforts, audits, overpayment identification and recovery, regulatory responses, special projects, and program integrity initiatives.

• Monitor new fraud schemes, billing anomalies, and trends, and suggest suitable actions.

• Facilitate the progression of investigative cases through onsite audits, visits, drive-bys, and interviews with members, providers, and witnesses.

• Perform additional duties as assigned.

• Adhere to all 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 2 years of experience in fraud, waste, and abuse investigations, healthcare investigations, claims audits, payment integrity, healthcare compliance, law enforcement investigations, or a similar investigative field is required.

• Experience in analyzing healthcare claims, medical records, billing and coding documentation, provider data, financial information, or related records is preferred.

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

• Must comply with applicable federal and state regulations, contractual obligations, privacy standards, investigative protocols, and organizational policies and procedures.

• Qualified candidates with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act.

🏝️ Benefits

• Competitive pay.

• Health insurance.

• 401K.

• Stock purchase plans.

• Tuition reimbursement.

• Paid time off plus holidays.

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

• Additional incentives may be included in the total compensation package.

• Equal opportunity employer committed to diversity.