SIU Investigator
Description We’re searching for an Investigator for the Special Investigative Unit, someone who works well in a fast-paced setting. In this position, you will assist the Director of Controls and Compliance and Special Investigative Unit (SIU) Manager in investigating Fraud, Waste and Abuse for providers and members. This includes data mining for potential intakes, performing preliminary analysis on provider cases, and assisting with projects focused on detecting and preventing fraud, waste, and abuse. Think you’ve got what it takes? Job Duties & Responsibilities • Conducts Fraud, Waste and Abuse (FWA) and related compliance investigations. • Completes detailed and extensive investigations in adherence with organization’s procedures and best practices. Gather evidence and determine potential recoveries. • Researches and prepares cases for clinical and legal reviews. • Conducts reviews of flagged claims and suspected FWA, identifying opportunities for improving payment accuracy and preventing FWA. • Analyzes compliance and FWA cases for root cause, trends, and tracks data to translate findings, and develops processes for improvement or investigation. • Prepares accurate, timely, unbiased, and detailed written reports and case summaries in compliance with corporate standard operating procedures and guidelines documenting investigative results. • Prepares referrals for preliminary investigations, including requesting medical records, creating forms, reports and updating logs. • Facilitates the recovery of inappropriate payments from FWA matters. • Drafts recoupment letters for FWA findings. • Supports other investigators in SIU operations. • Maintains case management log with investigative notes, reports, and summaries. • Proactively collaborates with line of business personnel to generate referrals. • Partners with the federal and state agencies on data requests and investigations. • Maintains organization’s confidential information in accordance with corporate policies, as well as state and federal laws, rules, and regulations regarding confidentiality. Skills & Requirements • Required High School Diploma or GED with a preferred bachelor's degree • Required 2 years claims examination, claims adjusting, fraud detection, or investigations/special investigations unit (SIU) experience, preferably in a healthcare environment Apply tot his job