Senior Investigator, Special Investigations Unit

Role Overview

• conduct high level, complex investigations of known or suspected acts of healthcare fraud and abuse
• Investigate matters of program integrity to prevent payment of aberrant claims submitted to the Medicaid lines of business for payment
• Conduct thorough research on subject(s) and related entities
• Initiate independently proactive data mining using SIU Tools to identify aberrant billing patterns and early scheme detection
• Conduct extensive analysis of claims data to determine aberrancy, pattern, or scheme
• Research and prepare cases for both clinical and legal review
• Collaborate with Medical Directors on clinical issues and medical record questions
• Accurately documents all case activity and communications in designated case tracking system
• Communicate clinical findings to provider
• Adherent to all regulatory requirements
• Facilitate case outcomes for the recovery of company and customer monies lost from aberrant billing
• Provide training and guidance to new and junior investigators
• Assist junior Investigators in identifying resources for cases; offer suggestions on investigative strategy
• Serve as back up to the Team Leader as necessary
• Collaborate with federal, state, and local law enforcement agencies for the investigation and prosecution of healthcare fraud issues
• Experience in witness testimony; Proficient in testifying for both civil and criminal proceedings
• Communicate clearly a high level of FWA knowledge and understanding during interactions with both internal and external stakeholders
• Communicate ideas on efficiency gains; provides input regarding controls for monitoring FWA among the business segments

Requirements

• 5+ years investigative experience in healthcare fraud and abuse matters
• Working knowledge of medical coding; CPT, HCPCS, ICD10
• Proficient in Microsoft Office with advanced skills in Excel and functions such as pivot tables
• Strong analytical ability to view and slice claims data in multiple facets
• Self-starter: initiates research that will be vital to an investigation
• Proficient in researching information and identifying new resources helpful to all cases
• Strong verbal and written communication skills (using correct grammar, spelling, sentence structure, etc.)
• Ability to travel up to 10% (approx. 2-3x per year, depending on business needs)

Benefits

• medical, dental, and vision coverage
• paid time off
• retirement savings options
• wellness programs