SIU Investigator

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

📋 Description

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

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

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

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

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

• Assist in audits, overpayment identification and recovery, regulatory responses, special projects, and program integrity initiatives.

• Monitor and assess emerging fraud schemes, billing discrepancies, and risks associated with healthcare programs.

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

• Execute other assigned duties as required.

• 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 experience in fraud, waste, and abuse investigations, healthcare investigations, claims audits, payment integrity, healthcare compliance, law enforcement investigations, or a related investigative area is required.

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

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

• Must comply with all 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

• Health insurance

• 401K

• Stock purchase plans

• Tuition reimbursement

• Paid time off plus holidays

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

• Additional forms of incentives may be included in total compensation

• Equal opportunity employer committed to diversity