SIU Investigator III (Must live in Georgia)

CareSource; Athens (GA); In loco; USD 72.000 - 116.000; Tempo pieno

Descrizione del lavoro

CareSource is seeking the Special Investigations Unit (SIU) III to lead complex healthcare fraud investigations. You will analyze provider billing data, coordinate investigative projects, and deliver outcomes that impact regulatory actions.

The role requires 5+ years in healthcare fraud investigations, strong data analytic skills, and the ability to work independently with limited supervision. Travel up to 10% may be required.

Competenze

• Minimum 5 years in healthcare fraud investigations or related field
• Bachelor’s Degree or equivalent in health-related field, law enforcement, or insurance
• Intermediate proficiency in Microsoft Office (Outlook, Word, Excel, Access, PowerPoint)
• Knowledge of CPT, HCPCS, ICD coding and medical billing preferred
• Ability to analyze data and articulate findings clearly
• Willingness to travel up to 10% as required

Mansioni

• Investigate and resolve high complexity healthcare fraud, waste and abuse cases
• Develop, coordinate and conduct strategic investigative projects
• Manage reports from detailed claims, eligibility, pharmacy, and clinical data
• Audit and oversee quality outcomes for the investigation team
• Coordinate on-site and desk audits of medical records and claims
• Prepare evidentiary documents for litigation and negotiate settlements

Conoscenze

Analytical thinking

Data analytics

Communication skills

Interpersonal skills

Leadership qualities

Ability to work with limited_supervis

Formazione

Bachelor's degree in health-related field / law enforcement / insurance

AHFI or CFE certification

NHCAA training or equivalent

Strumenti

Microsoft Office Suite

RAT STATS

Medical coding systems

Descrizione del lavoro

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. Develop, coordinate and conduct strategic fact-driven investigative projects including business process review, execution of investigative activities, and development of investigation outcome recommendations

Manage the development, production, and validation of reports generated from detailed claims, eligibility, pharmacy, and clinical data and translate analytical findings into actionable items

Ensure quality outcomes for investigative team through auditing and oversight

Report identified corporate financial impact issues

Use concepts and knowledge of coding guidelines to analyze complex provider claim submissions

Research, comprehend and interpret various state specific Medicaid, federal Medicare, and ACA/Exchange laws, rules and guidelines

Identify, research and comprehend medical standards, healthcare authoritative sources and apply knowledge to investigative approach

Collaborate with data analytics team and utilize RAT STATS on Statistically Valid Random Sampling

Coordinate and conduct on-site and desk audits of medical record reviews and claim audits

Manage and decision claims pended for investigative purposes

Maintain a working knowledge of all state and federal laws, rules, and billing guidelines for various provider specialty types

Participate in meetings with operational departments, business partners, and regulatory partners to facilitate investigative case development

Participate 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 litigation

Establish 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 prevention

SME in the designated market and ability to apply external intelligence to their analysis and case development

Attend fraud, waste, and abuse training/conferences, as needed

Support regulatory fraud, waste, and abuse reports to federal and state Medicare/Medicaid agencies

Manage and maintain sensitive confidential investigative information

Maintain compliance with state and federal laws and regulations and contracts

Adhere to the CareSource Corporate Compliance Plan and the Anti-Fraud Plan

Assist in Federal and State regulatory audits, as needed

Bachelor’s Degree or equivalent years of relevant work experience in Health-Related Field, Law Enforcement, or Insurance required

criminal justice, public health, mathematics, statistics, health economics, nursing) preferred

Minimum of five (5) years of experience in healthcare fraud investigations, medical coding, pharmacy, medical research, auditing, data analytics or related field is required

Intermediate proficiency level in Microsoft Office to include Outlook, Word, Excel, Access, and PowerPoint

Strong interpersonal skills, high level of professionalism, integrity and ethics in performance of all duties

Background in research and drawing conclusions

Ability to perform intermediate data analysis and to articulate understanding of findings

Ability to work under limited supervision with moderate latitude for initiative and independent judgment

Background in medical terminology, CPT, HCPCS, ICD codes or medical billing preferred

Complex project management skills preferred

Display leadership qualities

Accredited Healthcare Fraud Investigator (AHFI) or Certified Fraud Examiner (CFE)

NHCAA or other fraud and abuse investigation training is preferred

General office environment; Occasional travel (up to 10%) to attend meetings, training, and conferences may be required

72,200.00 - $115,500.00 CareSource takes into 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. Compensation Type (hourly/salary):

Cultivate Partnerships

Pursue Personal Excellence