Sr Investigator, SIU (Remote)

Job Description
Job Summary
The SIU Senior Investigator position is primarily responsible for supporting the day to day operations and initiatives of the Special Investigations Unit (SIU).
  Knowledge/Skills/Abilities
• Respond to all allegations of potential FWA. Conduct the investigation of fraudulent, wasteful and abusive activities involving members and providers
• Analyze enrollment data, medical claims data, contract terms, financial records, provider and member claims history, and other documentation to determine FWA and identify potential patterns. Apply regulatory and contractual requirements as well as internal policies and procedures to the case investigation process
• Perform data analysis, research and review of claims data to identify trends, patterns, outliers and emerging issues in healthcare fraud, waste and abuse with fraud technology
• Conduct investigations and interviews to gather additional evidence
• Research and investigate member Identity Theft cases through internal Alertline
• Communicate with members and providers routinely regarding issues including investigative findings, recoveries, and educational feedback where appropriate
• Compile, report and present case information to the appropriate Medicaid Fraud Control Unit or other regulatory agency
• Maintain the integrity of documentation for FWA cases. Update case management system to ensure documentation of all calls, evidence, referrals, inquiries and case events are accurate for record keeping purposes and for “Discovery” in court related cases
• Establish and maintain strong relationships with external agencies including the Department of Health, Office of Inspector General, Drug Enforcement Administration, state professional licensing boards, US Attorney's Office and state/local law enforcement
• Prepare data requests from external law enforcement agencies as required
• Willingness to travel in order to conduct provider onsite audits and investigations
• Write clear and concise reports, present findings to providers and participate in negotiated resolution of issues at the direction of management. Track and report any overpayment as a result of an investigation
• Use findings to determine where there is a need for a change in policy and course of appropriate action based on line of business, severity of issue, regulatory compliance requirements and plan exposure.
• Direct team members in the area of ideation and vetting new concepts for building additional investigation opportunities or clearer review guidelines for cases
• Assist SIU Management in case review and resolution
• Provide guidance to investigators as needed on investigative techniques, tools, or strategy.
• Effectively investigate and manage complex and non-complex fraud allegations.
• Develop and maintain relationships with key business units within specific product line and geographic region.
• Provides direction, instructions and guidance to Investigative team, particularly in the absence of the SIU Manager.
• Monitor team members' participation to ensure the training provided is effective, and if any additional training is needed.
• Create, edit, and update assigned reports to apprise the company on the team's progress.
• Performs other duties as assigned.
  Job Qualifications

Required Education
• Associates degree or Bachelor's degree in Health Information Management, Health Care Administration, Finance, Criminal Justice, Law Enforcement or related field (applicable FWA experience would be accepted in lieu of education experience)
Required Experience
• At least five (5) years experience working in a Managed Care Organization or health insurance company (preferably in an SIU)
• Proven investigatory skill; ability to organize, analyze, and effectively determine risk with corresponding solutions; ability to remain objective and separate facts from opinions
• Knowledge of investigative and law enforcement procedures with emphasis on fraud investigations
• Knowledge of Managed Care and the Medicaid and Medicare programs as well as Marketplace
• Understanding of claim billing codes, medical terminology, anatomy and health care delivery systems
• Understanding of datamining and use of data analytics to detect fraud, waste and abuse
• Proven ability to research and interpret regulatory requirements
• Effective interpersonal skills and customer service focus; ability to interact with individuals at all levels
• Excellent oral and written communication skills; presentation skills with ability to create and deliver training, informational and other types of programs
• Advanced skills in Microsoft Office (Word, Excel, PowerPoint, Outlook), SharePoint and Intra/Inter