SIU Investigator

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

📋 Description

• Conduct investigations into fraud, waste, and abuse (FWA) utilizing referrals, claims data, medical documentation, interviews, data analytics, and other investigative tools.

• Analyze, document, and sustain investigative activities, including findings, recommendations, and outcomes.

• Review claims, medical records, provider billing practices, enrollment data, financial documents, and additional relevant information.

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

• Collaborate with internal 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 risks to healthcare programs, 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

• 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 similar 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 relevant investigative, auditing, or compliance certifications.

• Compliance 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 working arrangements, including remote, hybrid, field, or office schedules

• Additional incentive options may be included in total compensation

• Equal opportunity employer committed to fostering diversity