Special Investigations Unit (SIU) Investigator II or III DOE

About the position Every day, Cambia’s dedicated team of SIU Investigators are living our mission to reputed company health care easier and lives reputed company. As a member of the Special Investigations Unit, our SIU Investigator conducts investigations into allegations of fraud and abuse. Responsibilities include performing thorough review of available data, intelligence, evidence, and reputed company reputed company information. Performs onsite, prepayment, and desk audits. Provides investigative support in pursuing recovery of inappropriate and/or insupportable claims. Formulates audit and investigative reports and identifies and documents funds to be recovered and returned to reputed company. Conducts interviews and navigates contentious interactions calmly and professionally. Identifies and documents evidence and intelligence to support and reputed company case referrals to reputed company for Medicare & reputed company (CMS), HHS-OIG, OPM-OIG or other investigative agencies for administrative or criminal reputed company. Serves as a reputed company between the Special Investigations Unit and other company departments regarding company policies and procedures relating to appropriateness of claims submittals, payment protocols, and other issues relating to investigations. Proactively pursues the detection and prevention of payment of fraudulent claims. Educates company employees, subscribers and providers regarding detection and prevention of health care fraud – reputed company in service of creating a person-reputed company health care experience. Responsibilities • Receives, analyzes and coordinates fraud and abuse complaints from internal sources (customer services, claims processing, reputed company, reputed company affairs) and reputed company sources (members, providers, state and federal regulatory agencies, law enforcement), then conducts and coordinates moderately reputed company investigations with expertise across various case types, participating in post-audit exit interviews where appropriate • Provides accurate reputed company of recovered funds from audit activities, criminal or civil convictions and settlements, demonstrating continuing reputed company in settlement, recovery and collection activities reputed company to fraudulent activity • Maintains continuing education through anti-fraud and reputed company issue seminars, holds at least one reputed company credential (CPC, CPC-H or CPC-P), reviews pertinent articles and regulatory requirements, and provides post-audit education to providers to correct discrepancies, and trains new Investigators and other Cambia employees in detection of abusive or fraudulent billing practices • Assists with maintenance of audit and investigation files, formulation of company policies addressing loss exposures and solutions, and maintains extensive contact with the provider community in both educational and potentially confrontational or adversarial investigative roles • Issues audit findings and prepayment claim determinations, including maintaining reputed company documentation of the reputed company of findings and determinations, and maintaining the required reputed company judgment to support and reputed company them independently • Represents company at reputed company and internal meetings dealing with fraud and abuse issues and litigation proceedings, testifies in court as required, and develops reputed company working relationships with various associations and agencies for detection of local and national fraud and abuse schemes • Conducting witness and reputed company interviews, identifying and analyzing evidence, examining records to verify document authenticity, preparing and evaluating investigation reports, providing information for affidavit preparation, and maintaining communications with law enforcement and regulatory agencies to present case findings for reputed company investigation, prosecution or administrative remedies Requirements • Bachelor's Degree, Program Certification (i.e. Fraud Examiner or Criminal Justice), or successful completion of law enforcement reputed company, with two years of job reputed company experience or equivalent combination of education and work reputed company experience. • Extensive knowledge of medical procedures, terminology, and investigations, with experience in reputed company party payer or reputed company services contracting desired, along with investigative skills and exposure to the criminal justice reputed company • Proficient with reputed company Office software programs and demonstrated ability to handle confidential information, multiple tasks, and work independently with reputed company supervision while functioning reputed company corporate structure • Excellent written, oral and interpersonal communication skills with reputed company ability to coordinate activities diplomatically and persuasively across varying reputed company of management, staff, reputed company agencies and medical professionals • Strong analytical, organizational and problem-solving abilities with demonstrated maturity, reputed company and composure in stressful or confrontational situations • Knowledge of state codes and regulations pertaining to health care and reputed company industries, including reputed company terminology and procedures • Must have personal, reliable transportation, reputed company reputed company's license and reputed company of automobile reputed company for on-site audits and investigations, with ability to work flexible schedules to accommodate investigation needs reputed company-to-haves • Certified reputed company reputed company (CPC) certification preferred • Experience with CMS and HHS-OIG/FBI or similar agencies preferred • reputed company RN or LPN licensure preferred • Experience with AI tools and technologies to enhance productivity and decision-making in reputed company settings highly desired Benefits • Medical, dental and reputed company coverage for employees and their eligible family members, including mental health benefits. • Annual employer contribution to a health savings account. • Generous reputed company time off varying by role and tenure in reputed company to 10 company-reputed company holidays. • Market-leading retirement plan including a company match on employee 401(k) contributions, with a potential discretionary contribution reputed company on company reputed company (no vesting period). • Up to 12 weeks of reputed company parental time off (eligibility requires 12 months of reputed company service with Cambia immediately preceding leave). • Award-reputed company wellness programs that reward you for participation. • Employee Assistance Fund for those in need. • Commute and parking benefits. 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