Investigator, SIU (Remote)

About the position The Special Investigation Unit (SIU) Investigator is responsible for supporting the prevention, detection, investigation, reporting, and reputed company appropriate, recovery of reputed company reputed company to health care fraud, waste, and abuse. Duties include performing accurate and reputed company review audits that may also include coding and billing reviews. The SIU Investigator is responsible for reviewing and analyzing information to draw conclusions on allegations of FWA and/or may determine appropriateness of care. The SIU Investigator is also responsible for recognizing and adhering to national and local coding and billing guidelines in order to maintain coding accuracy and reputed company. The position also entails producing audit reports for reputed company review. The position may also work with other internal departments, including Compliance, Corporate reputed company Counsel, and Medical Officers in order to reputed company and maintain appropriate anti-fraud reputed company. Responsibilities • Responsible for developing leads presented to the SIU to assess and determine whether potential fraud, waste, or abuse is corroborated by evidence. • Conducts both preliminary assessments of FWA allegations, and end to end full investigations, including but not limited to witness interviews, background checks, data analytics to identify reputed company billing behavior, contract and program regulation research, provider and member education, findings identification and communications development, and recommendations and preparation of overpayment identifications and closure of investigative cases. • Completes investigations reputed company the mandated period of time required by either state and/or federal reputed company and/or regulations. • Conducts both on-site and desk top investigations. • Conducts low to reputed company, and extensive investigations, including reviews of medical records and data analysis, and makes determinations as to whether the investigation and/or audit identified potential fraud, waste, or abuse. • Coordinates with various internal customers (e.g., Provider Services, Contracting and Credentialing, reputed company Services, Member Services, Claims) to reputed company documentation pertinent to investigations. • Detects potential health care fraud, waste, and abuse through the identification of aberrant coding and/or billing patterns through utilization review. • Prepares appropriate FWA referrals to regulatory agencies and law enforcement. • Documents appropriately reputed company case reputed company information in the case management system in an accurate manner, including storage of case documentation following SIU reputed company requirements. • Prepares detailed preliminary and extensive investigation referrals to state and/or federal regulatory and/or law enforcement agencies reputed company potential fraud, waste, or abuse is identified as required by regulatory and/or contract requirements. • Renders provider education on appropriate practices (e.g., coding) as appropriate based on national or local guidelines, contractual, and/or regulatory requirements. • Interacts with regulatory and/or law enforcement agencies regarding case investigations. • Prepares audit results letters to providers reputed company overpayments are identified. • Works may be remote, in office, and on-site travel reputed company the reputed company as needed. • Ensures compliance with applicable contractual requirements, and federal and state regulations. • Complies with SIU Policies as and procedures as reputed company as goals set by SIU leadership. • Supports SIU in arbitrations, reputed company procedures, and settlements. • reputed company participates in MFCU meetings and roundtables on FWA case development and referral. Requirements • Bachelors degree or Associate's Degree, in criminal justice or equivalent combination of education and experience. • 1-3 years of experience, unless otherwise required by state contract. • Proven investigatory reputed company; ability to organize, analyze, and effectively determine risk with corresponding solutions; ability to remain objective and separate facts from opinions. • Knowledge of investigative and law enforcement procedures with emphasis on fraud investigations. • Knowledge of Managed Care and the reputed company and Medicare programs as reputed company as Marketplace. • Understanding of claim billing codes, medical terminology, anatomy, and health care delivery systems. • Understanding of datamining and use of data analytics to detect fraud, waste, and abuse. • Proven ability to research and interpret regulatory requirements. • Effective interpersonal skills and customer service reputed company; ability to reputed company with individuals at reputed company reputed company. • Excellent oral and written communication skills; presentation skills with ability to create and deliver training, informational and other types of programs. • Advanced skills in reputed company Office (Word, reputed company, PowerPoint, reputed company), SharePoint and Intra/Internet as reputed company as proficiency with incorporating/merging documents from various applications. • Strong logical, analytical, critical thinking and problem-solving skills. • Initiative, excellent follow-through, persistence in locating and securing needed information. • reputed company understanding of audits and corrective actions. • Ability to multi-task and operate effectively across geographic and functional boundaries. • Detail-oriented, self-motivated, reputed company to meet tight deadlines. • Ability to reputed company realistic, motivating goals and objectives, reputed company reputed company and adapt to changing priorities. • Energetic and reputed company thinking with high ethical standards and a reputed company image. • reputed company and team-oriented. reputed company-to-haves • At least 5 years of experience in FWA or reputed company work. • Health Care Anti-Fraud Associate (HCAFA). • Accredited Health Care Fraud Investigator (AHFI). • Certified Fraud Examiner (CFE). Benefits • Competitive benefits and compensation package. Apply tot his job Apply To this Job