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, gather, and analyze data to identify trends, patterns, anomalies, and outliers in provider billing behavior.

• Act as a subject matter expert for fellow investigators.

• Develop, coordinate, and execute strategic, fact-driven investigative projects.

• Oversee the development, production, and validation of reports utilizing claims, eligibility, pharmacy, and clinical data.

• Convert analytical findings into actionable items to drive investigative results.

• Audit and monitor the quality outcomes of the investigative team.

• Prioritize, track, and report on investigation statuses.

• Report identified corporate financial impact issues.

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

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

• Apply medical standards and authoritative healthcare sources to investigative methods.

• Collaborate with data analytics teams and utilize RAT-STATS for statistically valid random sampling.

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

• Manage and decide on claims held for investigative purposes.

• Conduct in-depth, complex interviews.

• Execute and manage formal corrective action plans for providers.

• Collaborate with operational departments, business partners, regulatory partners, and Legal General Counsel to develop cases and pursue legal actions, corrective actions, negotiations, recoveries, settlements, and litigation documentation.

• Present, support, and defend investigative research for formal corrective actions.

• Maintain relationships with law enforcement agencies, task force members, SIU staff, and external fraud investigation contacts.

• Serve as a subject matter expert in the designated market and leverage external intelligence for case analysis and development.

• Develop and deliver internal and external formal presentations.

• Attend training and conferences focused on fraud, waste, and abuse.

• Support regulatory FWA reports to federal and state Medicare/Medicaid agencies.

• Manage sensitive, confidential investigative information.

• Ensure compliance with laws, regulations, contracts, the Corporate Compliance Plan, and the Anti-Fraud Plan.

• Assist with federal and state regulatory audits.

• Perform other job-related instructions as requested.

⛳️ Requirements

• Must reside in Arkansas.

• Bachelor's Degree or equivalent years of relevant experience in a health-related field, law enforcement, or insurance is required.

• At least 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 required: Accredited Healthcare Fraud Investigator (AHFI) or Certified Fraud Examiner (CFE).

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

• Effective listening and critical thinking skills; ability to identify gaps in logic.

• Strong interpersonal skills, professionalism, integrity, and ethics.

• Excellent problem-solving and decision-making abilities with a keen attention to detail.

• Background in research and drawing conclusions.

• Ability to perform intermediate data analysis and communicate findings effectively.

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

• Capability to manage a demanding investigative caseload.

• Ability to develop, prioritize, and achieve goals.

• Strong writing skills with the ability to compose detailed investigative reports and professional correspondence.

• Experience in presentations is beneficial.

• Knowledge of Medicaid, Medicare, and healthcare regulations is preferred.

• Background in medical terminology, CPT, HCPCS, ICD codes, or medical billing is preferred.

• Complex project management skills are preferred.

• Leadership qualities are a plus.

• Certified Professional Coder (CPC) is preferred.

• NHCAA or other fraud and abuse investigation training is preferred.

🏝️ Benefits

• Bonus linked to company and individual performance may be available.

• Comprehensive total rewards package.

• Occasional travel for meetings, training, and conferences.