Investigator, SIU (Remote)

Lensa; Warren (MI); Remote; USD 50,000 - 80,000; Full time

Job summary

An established industry player is seeking a dedicated SIU Investigator to join their team. This role involves investigating healthcare fraud, waste, and abuse, with responsibilities including conducting thorough audits, preparing detailed reports, and collaborating with various departments. The ideal candidate will have strong analytical skills, a background in criminal justice, and a commitment to ethical standards. This is an exciting opportunity to make a significant impact in the healthcare sector while working in a supportive and professional environment.

Qualifications

• 1-3 years of experience in fraud investigations or related fields.
• Proven skills in data analytics and investigative procedures.

Responsibilities

• Conduct investigations into healthcare fraud, waste, and abuse.
• Prepare detailed reports and referrals for regulatory agencies.
• Collaborate with internal departments for documentation.

Skills

Investigatory Skills

Data Analytics

Communication Skills

Analytical Skills

Problem-Solving Skills

Knowledge of Investigative Procedures

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 to achieve and maintain appropriate anti-fraud oversight.

Job Duties

• Responsible for developing leads presented to the SIU to assess and determine whether potential fraud, waste, or abuse is corroborated by evidence.
• 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 recommendations.
• Completes investigations within mandated timeframes required by state and/or federal regulations.
• Conducts both on-site and desk investigations.
• Performs low to extensive investigations, reviews of medical records and data analysis, and determines potential fraud, waste, or abuse.
• Coordinates with internal departments to gather documentation pertinent to investigations.
• Detects potential health care fraud, waste, and abuse through identification of aberrant billing patterns.
• Prepares FWA referrals to regulatory agencies and law enforcement.
• Documents case information accurately in the case management system, including storage of documentation.
• Prepares detailed investigation referrals when potential fraud, waste, or abuse is identified.
• Provides provider education on coding and billing practices based on guidelines and regulations.
• Interacts with regulatory and law enforcement agencies regarding investigations.
• Prepares audit results letters to providers when overpayments are identified.
• May work remotely, in-office, and travel within New York as needed.
• Ensures compliance with contractual, federal, and state regulations.
• Supports SIU in legal procedures and settlements.
• Participates in meetings and roundtables on FWA case development and referral.

Job Qualifications

Required Education

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

Required Experience/Skills

• 1-3 years of experience, or more depending on contract requirements.
• Proven investigatory skills; ability to analyze and determine risk; objective analysis.
• Knowledge of investigative procedures, fraud investigations, and healthcare programs.
• Understanding of claim billing codes, medical terminology, and healthcare systems.
• Data analytics skills for fraud detection.
• Research and interpret regulatory requirements.
• Effective interpersonal and communication skills.
• Proficiency in Microsoft Office, SharePoint, and document management.
• Strong analytical and problem-solving skills.
• Detail-oriented, self-motivated, able to meet deadlines.
• Ability to develop goals, track progress, and adapt.
• High ethical standards and professionalism.
• Team-oriented and collaborative approach.

Required License/Certification

• Valid driver’s license.

Preferred Experience and Certifications

At least 5 years in FWA or related work.

• HCAFA, AHFI, CFE certifications preferred.