Special Investigations Unit (SIU) Investigator
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Job Location:
Bloomington, IN - USA
Monthly Salary:
Not Disclosed
Posted on:
18 hours ago
Vacancies:
1 Vacancy
Job Summary
HealthPartners is hiring a Special Investigations Unit (SIU) Medical Review Investigator. The Medical Review Investigator is responsible for the intake investigation and resolution of potential Fraud Waste and Abuse (FWA) allegations involving Medicaid Medicare and Commercial (fully and self-insured) product lines. Primary responsibilities include evaluating allegations analyzing claims data reviewing medical records conducting interviews and performing investigative site visits. This role requires frequent collaboration with both internal departments and external stakeholders.
MINIMUM QUALIFICATIONS:
Education Experience or Equivalent Combination:
Bachelors degree in relevant field or 4-7 years of Investigative Experience
Knowledge Skills and Abilities:
- Proficient in using personal computers word processing and spreadsheets.
- Strong communication and stakeholder management skills.
- Proficient in drafting detailed and accurate written reports.
- Excellent presentation planning and organizational skills.
- Strong analytical skills with the ability to assess complex situations and identify effective solutions.
PREFERRED QUALIFICATIONS:
- Education Experience or Equivalent Combination:
- 2 years experience in medical fraud waste and abuse (FWA) investigations.
- Licensure/ Registration/ Certification:
- Professional certification as a Certified Fraud Examiner (CFE) Certified Professional Coder (CPC) Accredited Healthcare Fraud Investigator (AHFI) or similar.
- Knowledge Skills and Abilities:
- Experienced in using data analysis to uncover trends and patterns.
- Understanding of the current FWA landscape and trends with the ability to adapt to shifting priorities and evolving requirements.
- Demonstrated familiarity with CPT codes and terminology.
ESSENTIAL DUTIES:
- (70%) - Investigate allegations of potential FWA.
- (10%) Perform prepayment activities including obtaining and analyzing records.
- (10%) Prepare detailed investigation reports interview summaries and regulatory referrals.
- (10%) Identify opportunities for and contribute to FWA mitigation strategies including claim system edits outlier dashboards corrective action plans and reimbursement policies.
Additional Expectations:
- Manage an investigative caseload including timely documentation and reporting of case activities.
- Research and apply internal and external policies procedures laws and/or regulations.
- Identify and analyze suspicious billing patterns trends and anomalies.
- Interview professionals witnesses and patients/members.
- Perform investigative provider site visits.
- Collaborate with internal partners including Legal Compliance Contracting Credentialing Government Programs and the Health Plan Medical Directors
- Serve as an internal resource and subject matter expert on FWA.
- Demonstrate high standards of integrity and professionalism.
Key Skills
- Epidemiology
- Public Health
- Bank Secrecy Act
- Bioinformatics
- Fraud
- Genetics
- Interviewing
- Law Enforcement
- Qualitative Research Interviewing
- Research Experience
- Next Generation Sequencing
- Writing Skills
About Company
At HealthPartners we believe in the power of good – good deeds and good people working together. As part of our team, you’ll find an inclusive environment that encourages new ways of thinking, celebrates differences, and recognizes hard work. We’re a nonprofit, integrated health care ... View more
