Investigator, SIU (Remote)

Lensa; Des Moines (IA); Remote; USD 60,000 - 80,000; Full time

Job summary

A leading healthcare organization is seeking a Special Investigation Unit (SIU) Investigator to support the prevention and investigation of healthcare fraud. The role involves conducting audits, analyzing data, and collaborating with various departments to ensure compliance and accuracy in coding and billing practices. Candidates should have a background in criminal justice, strong analytical skills, and experience in fraud detection.

Qualifications

• 1-3 years of experience in FWA or related work.
• Knowledge of Managed Care, Medicaid, Medicare systems.
• Understanding of claim billing codes and medical terminology.

Responsibilities

• Conducts investigations into allegations of fraud, waste, and abuse.
• Prepares audit reports and documents case-related information.
• Coordinates with internal departments for investigation documentation.

Skills

Investigatory skills

Analytical skills

Interpersonal skills

Communication skills

Problem-solving skills

Education

Bachelor's degree in criminal justice

Associate's Degree in criminal justice

Tools

Microsoft Office

SharePoint

Document management systems

Job description

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Job Description

Job Summary

The Special Investigation Unit (SIU) Investigator is responsible for supporting the prevention, detection, investigation, reporting, and when appropriate, recovery of money related to health care fraud, waste, and abuse. Duties include performing accurate and reliable medical review audits that may also include coding and billing reviews. The SIU Investigator is responsible for reviewing and analyzing information to draw conclusions on allegations of FWA and/or may determine appropriateness of care. The SIU Investigator is also responsible for recognizing and adhering to national and local coding and billing guidelines in order to maintain coding accuracy and excellence. The position also entails producing audit reports for internal and external review. The position may also work with other internal departments, including Compliance, Corporate Legal Counsel, and Medical Officers in order to achieve and maintain appropriate anti-fraud oversight.

Job Duties

1. Responsible for developing leads presented to the SIU to assess and determine whether potential fraud, waste, or abuse is corroborated by evidence.
2. Conducts both preliminary assessments of FWA allegations, and end to end full investigations, including but not limited to witness interviews, background checks, data analytics to identify outlier billing behavior, contract and program regulation research, provider and member education, findings identification and communications development, and recommendations and preparation of overpayment identifications and closure of investigative cases.
3. Completes investigations within the mandated period of time required by either state and/or federal contracts and/or regulations.
4. Conducts both on-site and desk top investigations.
5. Conducts low to medium, and extensive investigations, including reviews of medical records and data analysis, and makes determinations as to whether the investigation and/or audit identified potential fraud, waste, or abuse.
6. Coordinates with various internal customers (e.g., Provider Services, Contracting and Credentialing, Healthcare Services, Member Services, Claims) to gather documentation pertinent to investigations.
7. Detects potential health care fraud, waste, and abuse through the identification of aberrant coding and/or billing patterns through utilization review.
8. Prepares appropriate FWA referrals to regulatory agencies and law enforcement.
9. Documents all case related information in the case management system accurately, including storage of case documentation following SIU requirements. Prepares detailed investigation referrals to state and/or federal agencies when potential fraud, waste, or abuse is identified.
10. Provides provider education on appropriate practices (e.g., coding) based on guidelines, contractual, and regulatory requirements.
11. Interacts with regulatory and law enforcement agencies regarding case investigations.
12. Prepares audit results letters to providers when overpayments are identified.
13. Work may be remote, in office, and involve on-site travel within New York as needed.
14. Ensures compliance with contractual, federal, and state regulations.
15. Supports SIU in legal procedures, arbitrations, and settlements.
16. Participates in MFCU meetings and roundtables on FWA case development and referral.

Job Qualifications

Required Education

Bachelor's degree or Associate’s Degree in criminal justice or equivalent experience.

Required Experience/Knowledge, Skills & Abilities

• 1-3 years of experience, unless otherwise required by state contract.
• Proven investigatory skills; ability to analyze and determine risk; objective assessment of facts.
• Knowledge of investigative and law enforcement procedures, especially related to fraud investigations.
• Knowledge of Managed Care, Medicaid, Medicare, and Marketplace programs.
• Understanding of claim billing codes, medical terminology, anatomy, and healthcare systems.
• Experience with data mining and analytics for fraud detection.
• Ability to interpret regulatory requirements.
• Strong interpersonal, communication, and presentation skills.
• Proficiency in Microsoft Office, SharePoint, and document management.
• Analytical, critical thinking, and problem-solving skills.
• Initiative, persistence, attention to detail, and ability to meet deadlines.
• Understanding of audits and corrective actions.
• Ability to multitask and work across boundaries.
• Self-motivated with high ethical standards and professionalism.
• Team-oriented and collaborative.

Required License, Certification, Association

• Valid driver’s license.

Preferred Experience

At least 5 years in FWA or related work.

Preferred License, Certification, Association

• HCAFA, AHFI, or CFE certifications preferred.