SIU Investigator III

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

📋 Description

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

• Assess business processes, carry out investigative tasks, and formulate recommendations based on investigation outcomes.

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

• Convert analytical findings into actionable strategies.

• Manage the strategic investigative plan and lead the team towards achieving investigative results.

• Ensure quality outcomes through comprehensive auditing and oversight.

• Organize, track, and report on the status of investigations.

• Report on identified corporate financial impact issues.

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

• Research and interpret laws, rules, and guidelines pertaining to state-specific Medicaid, federal Medicare, and ACA/Exchange.

• Implement medical standards and authoritative healthcare sources in investigative methodologies.

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

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

• Manage and make decisions regarding claims that are pending for investigative purposes.

• Prepare and conduct thorough and complex interviews.

• Execute and oversee formal corrective action plans for providers.

• Engage in meetings with operational departments, business partners, regulatory partners, and Legal General Counsel.

• Support legal actions, corrective measures, negotiations, recovery efforts, settlements, and litigation evidentiary documentation.

• Present, support, and advocate for investigative research in order to gain approval for formal corrective actions.

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

• Develop and deliver both internal and external formal presentations.

• Attend training and conferences on fraud, waste, and abuse as necessary.

• Assist with regulatory FWA reports submitted to federal and state Medicare/Medicaid agencies.

• Manage sensitive and confidential investigative information.

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

• Provide assistance during federal and state regulatory audits as needed.

⛳️ Requirements

• Residency in Georgia is mandatory.

• A Bachelor’s Degree or equivalent years of relevant 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 required: Accredited Healthcare Fraud Investigator (AHFI) or Certified Fraud Examiner (CFE).

• A Master’s Degree is preferred.

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

• Strong listening and critical thinking skills; capacity to identify logical gaps.

• Excellent interpersonal skills, professionalism, integrity, and ethical standards.

• Outstanding problem-solving and decision-making abilities with meticulous attention to detail.

• A background in research and the ability to draw conclusions.

• Capability to perform intermediate data analysis and articulate findings effectively.

• Capacity to work with minimal supervision while exercising moderate initiative and independent judgment.

• Ability to handle a demanding investigative caseload.

• Skills to develop, prioritize, and achieve goals.

• Proficient writing skills with the capability to create detailed investigative reports and professional internal and external correspondence.

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

• Familiarity with medical terminology, CPT, HCPCS, ICD codes, or medical billing is preferred.

• Preferred experience in complex project management.

• Occasional travel up to 10% may be required.

🏝️ Benefits

• Potential bonus linked to company and individual performance may be offered.

• A substantial and comprehensive total rewards package is available.

• Occasional travel for meetings, training sessions, and conferences may be required.