SIU Investigator III
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Job Description
SIU Investigator investigating complex healthcare fraud, waste, and abuse for CareSource. Analyzing claims, conducting audits, and managing corrective actions and regulatory investigations.
Responsibilities:
- 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
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