Senior SIU Investigator - CPC Required

Magellan Health; United States; On-site; USD 64,000 - 103,000; Full time

Benefits offered by this job

Short-term incentives

Comprehensive benefits package

Job summary

Magellan Health is seeking a Senior SIU Investigator - CPC to lead comprehensive investigations with substantial autonomy, focusing on fraud, waste, and abuse in healthcare. The role requires strong analytical skills and experience with Medicaid/Medicare like policies and reimbursement methodologies.

The candidate will prioritize cases, develop work plans, collect and analyze data from providers, members, and payment policies, and prepare investigative reports for internal stakeholders and law

Qualifications

• 7+ years of experience in fraud investigations or related behavioral/medical healthcare insurance experience in claims, clinical, auditing, compliance, provider networks, management, or project planning.
• Demonstrated abilities in time management and establishing priorities.
• Strong listening and observation skills- Impeccable work ethic, completely dependable, and proactive; a problem solver.
• Proven ability to effectively handle cases of fraud and abuse in a discreet, confidential, and professional manner.

Responsibilities

• Prioritize and manage workload to meet internal performance metrics, regulatory and contractual requirements.
• Use independent judgment to create investigative work plans and develop case strategies based upon analysis of referral data and contractual/regulatory requirements.
• Prepare clear and concise investigatory reports to support findings of potential fraud, waste and abuse.

Skills

Excel

Access

Outlook

Word

PowerPoint

Education

Bachelor's degree

AHFI

CFE

CPC

LSSBB

RN

Tools

Excel

Access

Outlook

Word

PowerPoint

Job description

This position is responsible for comprehensive management and ownership of fraud, waste and abuse investigations including development and presentation of investigative results. This individual carries out analytical and process management tasks with a high degree of autonomy. This individual serves as a corporate resource on fraud, waste and abuse issues and recommends cost containment projects with an emphasis on fraud prevention.

INVESTIGATIONS

Prioritize, triage and manage workload to meet internal performance metrics, regulatory and contractual requirements Use independent judgment to create investigative work plans and develop case strategies based upon analysis of referral data and contractual/regulatory requirements Analyze data and select audit samples using various sampling methodologies Plan and conduct desk audits, field audits and/or site visits Collect and analyze information to evaluate facts and circumstances through an extensive review of data from professional and facility providers, member data, contractual relationships, payment policies, Medicaid/Medicare rules and statutes, etc. Conduct research on medical policies and practices, provider characteristics, and related topics Interview patients, providers, provider staff, and other witnesses/experts Prepare correspondence Obtain and preserve physical and documentary evidence to support investigations Maintain comprehensive case files

FRAUD, WASTE AND ABUSE DETECTION

Triage and prioritize leads from internal and external sources Use knowledge of healthcare coding conventions, fraud schemes, and general areas of vulnerability, reimbursement methodologies, and relevant laws to find suspicious patterns in claims data, provider enrollment data, and other sources Remain up to date on published fraud cases, schemes, investigative techniques and methodologies, and industry trends

PACKAGING OF FINDINGS AND RECOMMENDATIONS

Organize data and prepare a written summary of investigative steps, conclusions, recommendations with attention to detail and a high level of accuracy Prepare clear and concise investigatory reports to support findings of potential fraud, waste and abuse

CASE RESOLUTION

Identify, communicate and recover losses as deemed appropriate Present case to internal department(s), law enforcement and/or regulatory agencies Support legal proceedings as needed, including testifying in court or working with law enforcement personnel to prepare cases for civil or criminal actions Negotiate settlement agreements with subjects and/or attorneys Assist in preparation, execution, and follow-up of settlement agreement terms

CUSTOMER INTERACTIONS

Make presentations to customers, prospects, conference audiences, and law enforcement Collaborate, consult, and coordinate regularly with clients on the status and direction of assignments Develop and maintain contacts/liaisons with law enforcement, regulatory agencies, task force members, other company SIU staff and external contacts involved in fraud investigation, detection and prevention

MISCELLANEOUS DUTIES

Provide guidance and training to SIU Investigators regarding case strategy, best practices, industry standards, Medicare/Medicaid requirements, industry trends, fraud schemes and other related areas Drive department efficiency and effectiveness through the recommendation and development of procedures and process flows and the implementation of industry best practices Represent client at industry task force meetings and meetings with regulatory agencies Measure and report performance metrics Identify opportunities and make recommendations for reduction of exposure to fraud, waste and abuse Consult on and develop anti-fraud policies and procedures Other duties as assigned.

Other Job Requirements Responsibilities

Minimum of 7 years of experience in fraud investigations or related behavioral/medical healthcare insurance experience in claims, clinical, auditing, compliance, provider networks, management, or project planning.

Demonstrated abilities in time management and establishing priorities.

Strong listening and observation skills- Impeccable work ethic, completely dependable, and proactive; a problem solver.

Proven ability to effectively handle cases of fraud and abuse in a discreet, confidential, and professional manner.

Demonstrated strategic and analytical thinking skills, with ability to effectively communicate conclusions and recommendations to management.

Comprehensive, practical knowledge of complex and diverse fraud investigative techniques and methodologies utilized in program audits.

Understanding of insurance terms and policy interpretation.

Ability to work to tight timelines when necessary.

Works independently; collaborates well with peers and customers.

Demonstrated ability to manage and prioritize case load with limited supervision.

Strong computer skills consisting of Microsoft Excel, Access, Outlook, Word, and Power Point.

General Job Information

• Title Senior SIU Investigator - CPC
• Required Grade 25
• Work Experience - Required
• Fraud Investigations Work Experience - Preferred
• Education - Required
• A Combination of Education and Work Experience May Be Considered.,
• Bachelor's Education - Preferred
• License and Certifications - Required
• License and Certifications - Preferred
• AHFI - Accredited Healthcare Fraud Investigator - EnterpriseEnterprise
• CFE - Certified Fraud Examiner - EnterpriseEnterprise
• CPC - Certified Professional Coder - EnterpriseEnterprise
• LSSBB - Lean Six Sigma Black Belt Certification - EnterpriseEnterprise
• RN - Registered Nurse, State and/or Compact State Licensure - Care MgmtCare Mgmt

Salary Range

Salary Minimum: $64,285 Salary Maximum: $102,855. This information reflects the anticipated base salary range for this position based on current national data. Minimums and maximums may vary based on location. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law.

Benefits

This position may be eligible for short-term incentives as well as a comprehensive benefits package. Magellan offers a broad range of health, life, voluntary and other benefits and perks that enhance your physical, mental, emotional and financial wellbeing.

Equal Opportunity and Security

Magellan Health, Inc. is proud to be an Equal Opportunity Employer and a Tobacco‑free workplace. EOE/M/F/Vet/Disabled. Every employee must understand, comply with and attest to the security responsibilities and security controls unique to their position; and comply with all applicable legal, regulatory, and contractual requirements and internal policies and procedures.

Company Culture

Magellan is the employer of choice for hard working people interested in making a difference in the health care industry and in the communities where we work and live. Our strong culture of caring is the common thread in both our business strategy and our work environment. We value professional growth and development, total health and wellness, rewards and recognition as well as employee unity. Magellan is a place where you can thrive.

Diversity, Equity, and Inclusion

Magellan is committed to providing equal employment opportunities to employees and applicants for employment without regard to race, color, creed, religion, sex, gender identity and expression, sexual orientation, marital status, age, national origin, ancestry, citizenship, physical or mental disability, disabled veteran or veteran of the Vietnam Era status, or any other factors protected by law.

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