SIU Investigator

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

📋 Description

• Conduct thorough investigations into suspected fraud, waste, and abuse from inception to conclusion.

• Formulate case plans that outline allegations, scope, and projected financial implications.

• Evaluate claims data to detect anomalous billing trends, assess overpayment risks, and assist with sampling and extrapolation.

• Examine medical records and supporting documents in accordance with CMS and TRICARE standards, payment policies, coding guidelines, and coverage decisions.

• Facilitate clinical and coding reviews in collaboration with internal teams.

• Engage in outreach to members and providers, including conducting investigative interviews.

• Maintain comprehensive and well-organized case files.

• Compose findings letters and determine overpayment amounts.

• Suggest corrective measures such as provider education, prepayment audits, recoupment strategies, and network actions.

• Prepare referrals to CMS Investigations MEDIC, the Defense Health Agency Program Integrity Office, HHS-OIG, and law enforcement agencies.

• Address information requests from oversight bodies.

• Keep precise case management records and assist with SIU reporting on recoveries, cost avoidance, and referrals.

• Monitor emerging fraud schemes and contribute to the development of new analytics and edits.

• Support FWA compliance requirements and help create FWA training materials.

• Help establish investigative standards, procedures, and collaborative workflows for the newly formed SIU.

• Report to the Director of the Special Investigations Unit.

⛳️ Requirements

• A Bachelor’s degree in criminal justice, health care administration, accounting, or a related field, or an equivalent blend of education and experience.

• A minimum of five years in health care fraud investigation, SIU, payment integrity, program integrity, or law enforcement related to health care fraud is required.

• Experience with Medicare Advantage is mandatory.

• Experience with TRICARE or other government programs is preferred.

• Familiarity with Medicare Advantage program integrity requirements, the False Claims Act, the Anti-Kickback Statute, the Stark Law, and obligations regarding overpayment reporting.

• Strong understanding of CMS-1500 and UB-04 claim formats and coding conventions.

• Proficient in investigative writing that can withstand legal and regulatory examination.

• Skilled in interviewing with sound judgment, discretion, and meticulous handling of protected health information (PHI).

• Advanced proficiency in Excel, SQL, PowerBI, or similar analytical tools is strongly preferred.

• Capable of working independently and contributing in a start-up atmosphere where procedures are still being established.

• At least one of the following certifications is preferred: AHFI, CFE, CPC, CCS, or CPMA.

• This position does not qualify for immigration sponsorship.

🏝️ Benefits

• Medical insurance

• Dental insurance

• Vision insurance

• Retirement savings plan with employer contributions

• Paid time off

• Volunteer time off

• Pie day

• Additional employee benefits