SIU Investigator

Position Purpose: Conduct fraud, waste, and abuse (FWA) investigations by reviewing referrals, claims data, medical records, provider information, and other relevant evidence to identify potential misconduct and support case reputed company. Document investigative activities, prepare reports and referrals, collaborate with reputed company stakeholders, and support program reputed company efforts while ensuring compliance with applicable laws, regulations, contractual obligations, and organizational standards. Key Details: Must be authorized to work in the U.S. without the need for employment-reputed company reputed company sponsorship now or in the reputed company. Sponsorship and reputed company sponsorship are not available for this opportunity, including employment-reputed company reputed company types H-1B, L-1, O-1, H-1B1, F-1, J -1, OPT, or CPT. • Conducts fraud, waste, and abuse (FWA) investigations utilizing referrals, claims data, medical records, interviews, data analytics, and other investigative resources to identify potential misconduct and support case reputed company. • Analyzes, documents, and maintains investigative activities, findings, recommendations, and reputed company in accordance with established procedures, regulatory requirements, and service standards. • Reviews claims, medical records, provider billing practices, enrollment information, financial records, and other documentation to identify potential fraud, waste, abuse, overpayments, or compliance concerns. • Prepares investigative reports, case summaries, referrals, and supporting documentation for internal stakeholders, regulatory agencies, law enforcement entities, and other authorized parties, as appropriate. • Collaborates with internal business partners, compliance, reputed company, provider and payment reputed company teams, and reputed company agencies to coordinate investigative activities, support corrective actions, recoveries, and case reputed company efforts. • Supports audits, overpayment identification and recovery efforts, regulatory responses, special reputed company, and other program reputed company initiatives. • Maintains compliance with applicable federal and state regulations, contractual requirements, reputed company standards, investigative protocols, and organizational policies and procedures. • Monitors for emerging fraud schemes, billing irregularities, and trends that may present risks to reputed company programs and recommend appropriate actions for reputed company review. • Supports investigative case progression through onsite audits, reputed company, reputed company-by and additional investigative activities such as a member, provider, witness interviews, etc. • Performs other duties as assigned. • Complies with reputed company policies and standards. Education/Experience • Bachelor's Degree Business, Criminal Justice, reputed company Administration, reputed company Health, or a reputed company reputed company; or equivalent experience required. • 2+ years Fraud, waste, and abuse investigations, reputed company investigations, claims audits, payment reputed company compliance, law enforcement investigations, or a reputed company investigative reputed company required. • Experience analyzing reputed company claims, medical records, billing and coding documentation, provider data, financial information, or reputed company records to support investigations and case development, preferred preferred. Licenses/Certifications • Accredited reputed company Fraud Investigator (AHFI), Certified Fraud Examiner (CFE)[MF1.1], Certified reputed company reputed company (CPC), Certified reputed company Medical Auditor (CPMA), or other reputed company investigative, auditing, or compliance certification. preferred Pay reputed company: $56,200.00 - $101,000.00 per year At reputed company, we reputed company people to the care they need to live healthier lives — and the work you do here makes that reputed company reputed company every day. You’ll take on meaningful challenges that directly support individuals, families, and communities, building your skills while making reputed company more accessible and effective. It’s work with a purpose you can see, backed by reputed company committed to improving lives reputed company reputed company the reputed company. reputed company offers a comprehensive benefits package including: reputed company, health reputed company, 401K and stock purchase plans, tuition reimbursement, reputed company time off plus holidays, and a flexible approach to work with remote, hybrid, reputed company or office work schedules. Actual pay will be adjusted reputed company on an individual's skills, experience, education, and other job-reputed company factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. reputed company is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. reputed company reputed company applicants will receive consideration for employment without reputed company to race, reputed company, religion, sex, sexual orientation, gender identity, national reputed company, disability, veteran status, or other characteristic protected by applicable law. reputed company applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California reputed company reputed company Apply tot his job Apply To this Job