SIU Investigator III

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

📋 Description

• Investigate and resolve complex allegations of healthcare fraud, waste, and abuse involving medical professionals, facilities, and members.

• Research, collect, and analyze claims, eligibility, pharmacy, and clinical data to identify trends, patterns, anomalies, and outliers.

• Develop, coordinate, and execute strategic, evidence-based investigative projects.

• Convert analytical findings into actionable recommendations and investigative results.

• Oversee strategic investigative plans, manage team workloads, audits, oversight, and report on investigation statuses.

• Analyze intricate provider claim submissions in accordance with coding guidelines.

• Interpret state Medicaid, federal Medicare, and ACA/Exchange laws, regulations, and guidelines.

• Perform both on-site and desk audits of medical records and claims.

• Manage and adjudicate claims that are pending for investigative purposes.

• Prepare and conduct complex interviews.

• Implement and oversee provider corrective action plans.

• Collaborate with operational, business, legal, regulatory, law enforcement, task force, analytics, and SIU partners.

• Assist in legal actions, negotiations, recovery efforts, settlement agreements, litigation documents, and formal corrective actions.

• Present investigative findings through internal or external presentations.

• Support the creation of regulatory FWA reports for federal and state Medicare/Medicaid agencies.

• Maintain confidentiality of investigative information while ensuring compliance with laws, regulations, contracts, and corporate anti-fraud strategies.

• Assist with federal and state regulatory audits and perform other related duties as assigned.

⛳️ Requirements

• Must reside in Arkansas.

• A Bachelor’s Degree or equivalent experience in a Health-Related Field, Law Enforcement, or Insurance is required.

• A minimum of five (5) years of experience in healthcare fraud investigations, medical coding, pharmacy, medical research, auditing, data analytics, or a related field is required.

• One of the following certifications is mandatory: Accredited Healthcare Fraud Investigator (AHFI) or Certified Fraud Examiner (CFE).

• Intermediate proficiency in Microsoft Office, including Outlook, Word, Excel, Access, and PowerPoint.

• Ability to identify logical gaps and perform intermediate data analysis.

• Strong interpersonal, written, problem-solving, decision-making, research, presentation, and project management skills.

• Capability to work with limited supervision while exercising moderate initiative and independent judgment.

• Ability to manage a demanding investigative caseload.

• Knowledge of Medicaid, Medicare, healthcare regulations, medical terminology, CPT, HCPCS, ICD codes, or medical billing is preferred.

• A Master’s Degree is preferred.

• Certification as a Professional Coder (CPC) is preferred.

• NHCAA or other training related to fraud and abuse investigations is preferred.

• Occasional travel up to 10% may be necessary.

🏝️ Benefits

• Bonus opportunities based on company and individual performance may be available.

• Comprehensive total rewards package.

• Occasional travel for meetings, training, and conferences.