SIU Investigator III

Job Description:

• Develop, coordinate, and conduct strategic, fact-driven investigative projects
• Review business processes, execute investigative activities, and develop investigation outcome recommendations
• Manage the development, production, and validation of reports using claims, eligibility, pharmacy, and clinical data
• Translate analytical findings into actionable items
• Manage the strategic investigative plan and drive team investigative outcomes
• Ensure quality outcomes through auditing and oversight
• Prioritize, track, and report investigation status
• Report identified corporate financial impact issues
• Analyze complex provider claim submissions using coding guidelines
• Research and interpret state-specific Medicaid, federal Medicare, and ACA/Exchange laws, rules, and guidelines
• Apply medical standards and healthcare authoritative sources to investigative approaches
• Collaborate with the data analytics team and use RAT-STATS for statistically valid random sampling
• Coordinate and conduct on-site and desk audits of medical records and claims
• Manage and make decisions on claims pended for investigative purposes
• Prepare and conduct in-depth complex interviews
• Execute and manage provider formal corrective action plans
• Participate in meetings with operational departments, business partners, regulatory partners, and Legal General Counsel
• Support legal actions, corrective actions, negotiations, recovery efforts, settlements, and litigation evidentiary documents
• Present, support, and defend investigative research for formal corrective action approval
• Maintain relationships with law enforcement agencies, task force members, SIU staff, and external fraud-investigation contacts
• Develop and present internal and external formal presentations
• Attend fraud, waste, and abuse training and conferences as needed
• Support regulatory FWA reports to federal and state Medicare/Medicaid agencies
• Manage sensitive confidential investigative information
• Maintain compliance with laws, regulations, contracts, the CareSource Corporate Compliance Plan, and Anti-Fraud Plan
• Assist with federal and state regulatory audits as needed

Requirements:

• Must live in Georgia
• Bachelor’s Degree or equivalent years of relevant work experience in a health-related field, law enforcement, or insurance required
• Minimum of five (5) years of experience in healthcare fraud investigations, medical coding, pharmacy, medical research, auditing, data analytics, or related field required
• One of the following certifications required: Accredited Healthcare Fraud Investigator (AHFI) or Certified Fraud Examiner (CFE)
• Master’s Degree preferred
• Intermediate proficiency in Microsoft Office, including Outlook, Word, Excel, Access, and PowerPoint
• Effective listening and critical thinking skills; ability to identify gaps in logic
• Strong interpersonal skills, professionalism, integrity, and ethics
• Excellent problem-solving and decision-making skills with attention to detail
• Background in research and drawing conclusions
• Ability to perform intermediate data analysis and articulate understanding of findings
• Ability to work under limited supervision with moderate latitude for initiative and independent judgment
• Ability to manage a demanding investigative caseload
• Ability to develop, prioritize, and accomplish goals
• Strong writing skills and ability to compose detailed investigative reports and professional internal and external correspondence
• Knowledge of Medicaid, Medicare, and healthcare rules preferred
• Background in medical terminology, CPT, HCPCS, ICD codes, or medical billing preferred
• Complex project management skills preferred
• Occasional travel up to 10% may be required

Benefits:

• Bonus tied to company and individual performance may be available
• Substantial and comprehensive total rewards package
• Occasional travel to attend meetings, training, and conferences