SIU Investigator

This is a fully remote position, open to applicants in Florida, +11 more states.

📋 Description

• Conduct investigations related to 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 outcomes.

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

• Prepare investigative reports, case summaries, referrals, and supporting documentation.

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

• Assist in corrective actions, recoveries, audits, overpayment identification, 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.

• Execute other assigned duties as necessary.

• Adhere to all policies and standards.

⛳️ Requirements

• 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.

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

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

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

• Qualified applicants 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 arrangements with options for remote, hybrid, field, or office schedules.

• Additional incentives may be included in total compensation.

• Equal opportunity employer committed to diversity.