SIU Investigator
SIU Investigator
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Job Description
Were searching for an Investigator for the Special Investigative Unit someone who works well in a fast-paced this position you will assist the Director of Controls and Compliance and Special Investigative Unit (SIU) Manager in investigating Fraud Waste and Abuse for providers and members. This includes data mining for potential intakes performing preliminary analysis on provider cases and assisting with projects focused on detecting and preventing fraud waste and abuse.
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Job Duties & Responsibilities
Conducts Fraud Waste and Abuse (FWA) and related compliance investigations.
Completes detailed and extensive investigations in adherence with organizations procedures and best practices. Gather evidence and determine potential recoveries.
Researches and prepares cases for clinical and legal reviews.
Conducts reviews of flagged claims and suspected FWA identifying opportunities for improving payment accuracy and preventing FWA.
Analyzes compliance and FWA cases for root cause trends and tracks data to translate findings and develops processes for improvement or investigation.
Prepares accurate timely unbiased and detailed written reports and case summaries in compliance with corporate standard operating procedures and guidelines documenting investigative results.
Prepares referrals for preliminary investigations including requesting medical records creating forms reports and updating logs.
Facilitates the recovery of inappropriate payments from FWA matters.
Drafts recoupment letters for FWA findings.
Supports other investigators in SIU operations.
Maintains case management log with investigative notes reports and summaries.
Proactively collaborates with line of business personnel to generate referrals.
Partners with the federal and state agencies on data requests and investigations.
Maintains organizations confidential information in accordance with corporate policies as well as state and federal laws rules and regulations regarding confidentiality.
Skills & Requirements
Required High School Diploma or GED with a preferred bachelors degree
Required 2 years claims examination claims adjusting fraud detection or investigations/special investigations unit (SIU) experience preferably in a healthcare environment
Employment Type
Full-Time
