SIU Investigator

Job Description

Are you a highly analytical and experienced investigator with a passion for uncovering the truth and protecting vital healthcare resources? Our Special Investigations Unit (SIU) is looking for a skilled Investigator to join our dedicated team. In this crucial role, you'll be at the forefront of preventing, detecting, and responding to healthcare fraud, waste, and abuse (FWA), safeguarding our members and the integrity of the Medicare Fund.

If you're driven by meticulous investigation, data-driven insights, and a commitment to justice, we encourage you to apply.

Are you a highly analytical and experienced investigator with a passion for uncovering the truth and protecting vital healthcare resources? Our Special Investigations Unit (SIU) is looking for a skilled Investigator to join our dedicated team. In this crucial role, you'll be at the forefront of preventing, detecting, and responding to healthcare fraud, waste, and abuse (FWA), safeguarding our members and the integrity of the Medicare Fund.

If you're driven by meticulous investigation, data-driven insights, and a commitment to justice, we encourage you to apply.

As an SIU Investigator, you'll be responsible for the full lifecycle of complex FWA investigations, acting as a subject matter expert and collaborating with various stakeholders. Your key responsibilities will include:

• Lead Complex Investigations: Plan, organize, and execute specialized investigations into allegations of healthcare fraud, waste, and abuse. This includes handling intricate cases requiring advanced investigative knowledge and skills.
• Data-Driven Detection: Utilize advanced data mining and analysis techniques to identify aberrancies and outliers in claims, medical records, enrollment, and other healthcare transactions. You'll independently research FWA issues and employ cutting‑edge investigative resources.
• Expert Guidance: Serve as a subject matter ملم expert for other SIU Investigators, providing specialized knowledge and guidance to elevate team capabilities.
• Policy & Strategy Development: Contribute to the development of robust policies and procedures related för FWA detection and investigation, as well as the annual SIU risk assessment and work plan.
• Thorough Documentation & Reporting: Conduct comprehensive FWA investigations, ensuring complete and accurate case documentation and detailed investigative reports that adhere to SIU policies and standards.
• External Referrals &
  
  Collaboration:
  
  Prepare comprehensive summary and detailed reports on investigative findings for referral to federal and state agencies, ensuring full compliance with regulatory requirements. You'll also actively participate in OIG Healthcare Fraud Work groups.
• Stakeholder Engagement: Collaborate closely with internal stakeholders (e.g., FWA Monthly Workgroup, Market/Network, Credentialing Committee) to share updates on FWA schemes, coordinate recommendations, and facilitate fund recovery or other necessary actions.
• Provider
  
  Education:
  
  Conduct impactful provider education sessions as a direct response to investigation findings and audits.
• Liaison & Point of Contact: Serve as a key point of contact for corporate and field inquiries regarding FWA, and participate in meetings with providers, business partners, regulatory agencies, and law enforcement.
• Training & Development: Assist in developing and presenting engaging FWA training programs for internal and external audiences.

• Education: A Bachelor’s Degree in Business, Criminal Justice, Healthcare, or a related field, or equivalent relevant work experience.
• Experience: Minimum of 3 years of dedicated experience in health insurance fraud investigation
  . Proven experience within Medicare and/or Medicaid programs
  , specifically with medical claim billing, reimbursement, audit, or provider contracting. Demonstrated experience with data analysis techniques.
  
  Experience with the Healthcare Fraud Shield platform is a significant plus
  .
• Exceptional Analytical
  
  Skills:
  
  Ability touse interrogate and dissect complex data sets, identifying patterns and anomalies indicative of FWA.
• Outs…