SIU Investigator

This is a fully remote position, open to applicants in Connecticut, +6 more states.

📋 Description

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

• Analyze, document, and uphold investigative activities, findings, recommendations, and outcomes.

• Review claims, medical records, provider billing practices, enrollment information, financial records, and additional documentation.

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

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

• Support corrective actions, recoveries, audits, overpayment identification and recovery efforts, regulatory responses, special projects, and program integrity initiatives.

• Monitor emerging fraud schemes, billing irregularities, and trends, recommending appropriate actions.

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

• Perform additional duties as assigned.

• Adhere to all policies and standards.

⛳️ Requirements

• Must be authorized to work in the U.S. without the necessity for employment-based visa sponsorship now or at any point in the future.

• 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 related investigative field is required.

• Preferred experience includes analyzing healthcare claims, medical records, billing and coding documentation, provider data, financial information, or related records to support investigations and case development.

• Preferred certifications include Accredited Healthcare Fraud Investigator (AHFI), Certified Fraud Examiner (CFE), Certified Professional Coder (CPC), Certified Professional Medical Auditor (CPMA), or other related investigative, auditing, or compliance certifications.

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

🏝️ Benefits

• Competitive pay.

• Health insurance.

• 401K plan.

• Stock purchase plans.

• Tuition reimbursement.

• Paid time off plus holidays.

• Flexible work approach with options for remote, hybrid, field, or office work schedules.

• Additional forms of incentives may be included in total compensation.

• Equal opportunity employer committed to diversity.