SIU Investigator

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

📋 Description

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

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

• Review claims, medical records, provider billing practices, enrollment data, financial documentation, and other relevant records.

• Prepare reports on investigations, case summaries, referrals, and accompanying documentation.

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

• Assist with audits, efforts to identify and recover overpayments, regulatory responses, special projects, and program integrity initiatives.

• Monitor new fraud schemes, billing discrepancies, and trends, and suggest appropriate measures.

• Aid in case progress through onsite audits, visits, drive-by activities, and interviews.

• Carry out other assigned duties and adhere to all policies and standards.

⛳️ Requirements

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

• A minimum of 5 years in the healthcare sector focusing on fraud, waste, and abuse investigations and audits, or at least 5 years in insurance claims investigation experience, or professional investigative experience with law enforcement agencies, or over 7 years of professional investigation experience related to economic or insurance matters is required.

• Experience in analyzing healthcare claims, medical records, billing, and coding documentation, provider data, financial information, or similar records to aid investigations and case development is preferred.

• Must be authorized to work in the U.S. without the need for employment-based visa sponsorship, now or in the future.

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

🏝️ Benefits

• Competitive pay

• Health insurance

• 401K and stock purchase plans

• Tuition reimbursement

• Paid time off plus holidays

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

• Additional incentives may be included in total compensation