Investigator, SIU (Remote)

Lensa; Jacksonville (FL); Remote; USD 55,000 - 75,000; Full time

Job summary

A leading company is seeking a Special Investigation Unit (SIU) Investigator to support the prevention and investigation of healthcare fraud. The role involves conducting thorough audits, analyzing data, and collaborating with various departments to ensure compliance and uphold ethical standards.

Qualifications

• 1-3 years of experience in FWA or related field.
• Knowledge of fraud investigation procedures and healthcare systems.

Responsibilities

• Conducts investigations of fraud, waste, and abuse allegations.
• Prepares detailed investigation referrals for regulatory agencies.
• Documents case information accurately in the case management system.

Skills

Investigatory skills

Data analytics

Interpersonal skills

Analytical skills

Problem-solving skills

Education

Bachelor’s or Associate’s Degree in criminal justice

Tools

Microsoft Office

SharePoint

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 investigations, including witness interviews, background checks, data analytics, contract research, provider and member education, findings identification, and report development.
3. Completes investigations within mandated timeframes according to state and/or federal regulations.
4. Conducts on-site and desk investigations.
5. Performs low to extensive investigations, reviews medical records, analyzes data, and determines potential fraud, waste, or abuse.
6. Coordinates with internal departments to gather documentation pertinent to investigations.
7. Detects potential healthcare fraud, waste, and abuse through coding and billing pattern analysis.
8. Prepares FWA referrals to regulatory agencies and law enforcement.
9. Documents case information accurately in the case management system, including case documentation storage.
10. Prepares detailed investigation referrals for regulatory and law enforcement agencies when needed.
11. Provides provider education on coding and practices based on guidelines and regulations.
12. Interacts with regulatory and law enforcement agencies regarding cases.
13. Prepares audit results letters to providers for overpayments.
14. May work remotely, in-office, and travel within New York as needed.
15. Ensures compliance with contractual, federal, and state regulations.
16. Supports SIU in legal procedures and settlements.
17. Participates in MFCU meetings and FWA case development roundtables.

Job Qualifications

Required Education

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

Required Experience/Skills

• 1-3 years of experience in FWA or related field.
• Investigatory skills, organization, analysis, objectivity.
• Knowledge of fraud investigation procedures, Managed Care, Medicaid, Medicare, and Marketplace programs.
• Understanding of billing codes, medical terminology, and healthcare systems.
• Data analytics and datamining skills.
• Regulatory research skills.
• Interpersonal, communication, and presentation skills.
• Proficiency in Microsoft Office, SharePoint, and document merging.
• Analytical, problem-solving, and detail-oriented skills.
• Ability to multi-task, meet deadlines, and work across boundaries.
• High ethical standards and professionalism.

License/Certifications

• Valid driver’s license.

Preferred Experience and Certifications

At least 5 years in FWA.

• HCAFA, AHFI, CFE certifications preferred.