Responsible for investigating and resolving high complexity allegations of healthcare fraud, waste and abuse (FWA) by medical professionals, facilities, and members
Research, gather, and analyze data to identify trends, patterns, aberrancies, and outliers in provider billing behavior
Serve as a subject matter expert for other investigators
Develop, coordinate and conduct strategic fact-driven investigative projects
Manage the development, production, and validation of reports generated from detailed claims, eligibility, pharmacy, and clinical data
Ensure quality outcomes for investigative team through auditing and oversight
Use knowledge of coding guidelines to analyze complex provider claim submissions
Prepare and conduct in-depth complex interviews relevant to investigative plan

Bachelor’s Degree or equivalent years of relevant work experience in 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 is required
Intermediate proficiency level in Microsoft Office to include Outlook, Word, Excel, Access, and PowerPoint
Knowledge of Medicaid, Medicare, healthcare rules preferred
Background in medical terminology, CPT, HCPCS, ICD codes or medical billing preferred

SIU Investigator III, Health Plan Experience Required

Key skills