SIU Investigator III (Must live in Arkansas)

CareSource; Little Rock (AR); On-site; USD 65,000 - 104,000; Full time

Job summary

CareSource is seeking a Senior Investigator in Arkansas to lead high-complexity fraud investigations in healthcare. You will research data, identify patterns, and develop action plans with cross-functional teams.

The role requires expert knowledge of Medicaid/Medicare rules and strong reporting abilities. The incumbent will manage audits, interviews, and corrective actions, collaborating with Legal Counsel and regulatory partners to drive cases and settlements.

Qualifications

• Bachelor’s Degree or equivalent years of relevant work experience in Health-Related Field, Law Enforcement, or Insurance required.
• Master’s Degree preferred (criminal justice, public health, mathematics, statistics, health economics, nursing).
• Minimum of five years of healthcare fraud investigations, medical coding, pharmacy, data analytics or related field.

Responsibilities

• Develop, coordinate and conduct strategic fact-driven investigative projects.
• Produce reports from detailed claims, eligibility, pharmacy, and clinical data.
• Translate analytical findings into actionable items for investigations.
• Coordinate on-site and desk audits of medical records and claims.
• Prepare complex interviews and support legal actions and settlements.

Skills

Analytical thinking

Written communication

Interpersonal skills

Problem solving

Presentation experience

Data analysis

Education

Bachelor’s degree in health-related field

Master’s degree preferred

Tools

RAT STATS

Microsoft Office

Job description

Job Summary

The Special Investigations Unit (SIU) III is responsible for investigating and resolving high complexity allegations of healthcare fraud, waste and abuse (FWA) by medical professional, facilities, and members. Researches, gathers, and analyzes data to identify trends, patterns, aberrancies, and outliers in provider billing behavior. Serves as a subject matter expert for other investigators. Must reside in Arkansas.

Essential Functions

Develop, coordinate and conduct strategic fact-driven investigative projects including business process review, execution of investigative activities, and development of investigation outcome recommendationsManage the development, production, and validation of reports generated from detailed claims, eligibility, pharmacy, and clinical data and translate analytical findings into actionable itemsManage strategic investigative plan and drive investigative outcome for the teamEnsure quality outcomes for investigative team through auditing and oversightPrioritize, track, and report status of investigationsReport identified corporate financial impact issuesUse concepts and knowledge of coding guidelines to analyze complex provider claim submissionsResearch, comprehend and interpret various state specific Medicaid, federal Medicare, and ACA/Exchange laws, rules and guidelinesIdentify, research and comprehend medical standards, healthcare authoritative sources and apply knowledge to investigative approachCollaborate with data analytics team and utilize RAT STATS on Statistically Valid Random SamplingCoordinate and conduct on-site and desk audits of medical record reviews and claim auditsManage and decision claims pended for investigative purposesMaintain a working knowledge of all state and federal laws, rules, and billing guidelines for various provider specialty typesPrepare and conduct in-depth complex interviews relevant to investigative planExecute and manage provider formal corrective action plansParticipate in meetings with operational departments, business partners, and regulatory partners to facilitate investigative case developmentParticipate in meetings with Legal General Counsel to drive case legal actions, formal corrective actions, negotiations with recovery efforts, settlement agreements, and preparation of evidentiary documents for litigationPresent, support, and defend investigative research to seek approval for formal corrective actionsEstablish and maintain relationships with Federal and State law enforcement agencies, task force members, other company SIU staff and external contacts involved in fraud investigation, detection and preventionSME in the designated market and ability to apply external intelligence to their analysis and case developmentDevelop and present internal and external formal presentations, as neededAttend fraud, waste, and abuse training/conferences, as neededSupport regulatory fraud, waste, and abuse reports to federal and state Medicare/Medicaid agenciesManage and maintain sensitive confidential investigative informationMaintain compliance with state and federal laws and regulations and contractsAdhere to the CareSource Corporate Compliance Plan and the Anti-Fraud PlanAssist in Federal and State regulatory audits, as neededPerform any other job-related instructions, as requested

Education and Experience

Bachelor’s Degree or equivalent years of relevant work experience in Health-Related Field, Law Enforcement, or Insurance requiredMaster’s Degree (e.g., criminal justice, public health, mathematics, statistics, health economics, nursing) preferredMinimum of five (5) years of experience in healthcare fraud investigations, medical coding, pharmacy, medical research, auditing, data analytics or related field is required

Competencies, Knowledge and Skills

Intermediate proficiency level in Microsoft Office to include Outlook, Word, Excel, Access, and PowerPointEffective listening and critical thinking skills and the ability to identify gaps in logicStrong interpersonal skills, high level of professionalism, integrity and ethics in performance of all dutiesExcellent problem solving and decision making skills with attention to detailsBackground in research and drawing conclusionsAbility to perform intermediate data analysis and to articulate understanding of findingsAbility to work under limited supervision with moderate latitude for initiative and independent judgmentAbility to manage demanding investigative case loadAbility to develop, prioritize and accomplish goalsSelf-motivated, self-directedStrong written skills with ability to compose detailed investigative reports and professional internal and external correspondencesPresentation experience, beneficialKnowledge of Medicaid, Medicare, healthcare rules preferredBackground in medical terminology, CPT, HCPCS, ICD codes or medical billing preferredComplex project management skills preferredDisplay leadership qualities

Licensure and Certification

One of the following certifications is required: Accredited Healthcare Fraud Investigator (AHFI) or Certified Fraud Examiner (CFE)Certified Professional Coder (CPC) is preferredNHCAA or other fraud and abuse investigation training is preferred

Working Conditions

General office environment; may be required to sit or stand for extended periods of timeOccasional travel (up to 10%) to attend meetings, training, and conferences may be required

Compensation Range

$64,980.00 - $103,950.00 CareSource takes in consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.

Compensation Type (hourly/salary)

Salary

Organization Level Competencies

• Fostering a Collaborative Workplace Culture
• Cultivate Partnerships
• Develop Self and Others
• Drive Execution
• Influence Others
• Pursue Personal Excellence
• Understand the Business

This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.