SIU Investigator

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

📋 Description

• As a SIU Investigator, you will oversee the complete lifecycle of intricate FWA investigations, serving as a subject matter expert while collaborating with various stakeholders.

• Lead Complex Investigations: Strategically plan, organize, and carry out specialized inquiries into claims of healthcare fraud, waste, and abuse.

• Data-Driven Detection: Employ advanced data mining and analysis methods to pinpoint irregularities and outliers in claims, medical records, enrollment, and other healthcare transactions.

• Expert Guidance: Act as a subject matter expert for fellow SIU Investigators, providing specialized insights and support to enhance team proficiency.

• Policy & Strategy Development: Play a role in creating comprehensive policies and procedures related to FWA detection and investigation, in addition to the annual SIU risk assessment and work plan.

• Thorough Documentation & Reporting: Execute detailed FWA investigations, ensuring complete and accurate case documentation alongside thorough investigative reports that comply with SIU policies and standards.

• External Referrals & Collaboration: Compile comprehensive summaries and detailed reports on investigative outcomes for submission to federal and state agencies, ensuring adherence to regulatory requirements.

• Stakeholder Engagement: Work closely with internal stakeholders to provide updates on FWA schemes, coordinate recommendations, and facilitate fund recovery or other necessary actions.

• Provider Education: Lead impactful educational sessions for providers in direct response to findings from investigations and audits.

• Liaison & Point of Contact: Act as a primary contact for corporate and field inquiries concerning FWA, and engage in meetings with providers, business partners, regulatory agencies, and law enforcement.

• Training & Development: Support the creation and delivery of engaging FWA training programs for both internal and external audiences.

⛳️ Requirements

• A Bachelor’s Degree in Business, Criminal Justice, Healthcare, or a related field, or equivalent relevant work experience.

• At least 3 years of dedicated experience in health insurance fraud investigation.

• Proven experience within Medicare and/or Medicaid programs, particularly in medical claim billing, reimbursement, auditing, or provider contracting.

• Demonstrated proficiency in data analysis techniques.

• Familiarity with the Healthcare Fraud Shield platform is a significant advantage.

• Ability to interpret and analyze complex data sets, identifying patterns and anomalies indicative of FWA.

• Must have demonstrated experience with AI tools.

• Exceptional written and verbal communication skills are crucial for clear report writing, compelling presentations, and effective stakeholder engagement.

• A strong commitment to integrity and compliance, along with meticulous attention to detail in all investigative aspects.

• Proven capability to work independently, manage a diverse caseload of investigations, and excel in a fast-paced environment, while also thriving in collaborative team settings.

• Highly organized with the ability to manage multiple complex investigations simultaneously and effectively prioritize tasks.

• Certified Fraud Examiner (CFE).

• Certified Professional Coder (CPC).

🏝️ Benefits

• Employer sponsored health, dental and vision plan with low or no premium.

• Generous paid time off.

• $100 monthly mobile or internet stipend.

• Stock options for all employees.

• Bonus eligibility for all roles excluding Director and above.

• Commission eligibility for Sales roles.

• Parental leave program.

• 401K program.

• And more....