SIU Investigator III; live in MA or states

Job Summary

The Special Investigations Unit (SIU) III is responsible for investigating and resolving high complexity allegations of healthcare fraud, waste and abuse (FWA) by medical professional, facilities, and members. Researches, gathers, and analyzes data to identify trends, patterns, aberrancies, and outliers in provider billing behavior. Serves as a subject matter expert for other investigators. Qualified candidates must live in Massachusetts or surrounding states.

• Develop, coordinate and conduct strategic fact-driven investigative projects including business process review, execution of investigative activities, and development of investigation outcome recommendations
• Manage the development, production, and validation of reports generated from detailed claims, eligibility, pharmacy, and clinical data and translate analytical findings into actionable items
• Manage strategic investigative plan and drive investigative outcome for the team
• Ensure quality outcomes for investigative team through auditing and oversight
• Prioritize, track, and report status of investigations
• Report identified corporate financial impact issues
• Use concepts and knowledge of coding guidelines to analyze complex provider claim submissions
• Research, comprehend and interpret various state specific Medicaid, federal Medicare, and ACA/Exchange laws, rules and guidelines
• Identify, research and comprehend medical standards, healthcare authoritative sources and apply knowledge to investigative approach
• Collaborate with data analytics team and utilize RAT STATS on Statistically Valid Random Sampling
• Coordinate and conduct on-site and desk audits of medical record reviews and claim audits
• Manage and decision claims pended for investigative purposes
• Maintain a working knowledge of all state and federal laws, rules, and billing guidelines for various provider specialty types
• Prepare and conduct in-depth complex interviews relevant to investigative plan
• Execute and manage provider formal corrective action plans
• Participate in meetings with operational departments, business partners, and regulatory partners to facilitate investigative case development
• Participate in meetings with Legal General Counsel to drive case legal actions, formal corrective actions, negotiations with recovery efforts, settlement agreements, and preparation of evidentiary documents for litigation
• Present, support, and defend investigative research to seek approval for formal corrective actions
• Establish and maintain relationships with Federal and State law enforcement agencies, task force members, other company SIU staff and external contacts involved in fraud investigation, detection and prevention
• SME in the designated market and ability to apply external intelligence to their analysis and case development
• Develop and present internal and external formal presentations, as needed
• Attend fraud, waste, and abuse training/conferences, as needed
• Support regulatory fraud, waste, and abuse reports to federal and state Medicare/Medicaid agencies
• Manage and maintain sensitive confidential investigative information
• Maintain compliance with state and federal laws and regulations and contracts
• Adhere to the Care Source Corporate Compliance Plan and the Anti-Fraud Plan
• Assist in Federal and State regulatory audits, as needed
• Perform any other job-related instructions, as requested

• Bachelor’s Degree or equivalent years of relevant work experience in Health-Related Field, Law Enforcement, or Insurance required
• Master’s Degree (e.g., criminal justice, public health, mathematics, statistics, health economics, nursing) preferred
• 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 Power Point
• Effective listening and critical thinking skills and the ability to identify gaps in logic
• Strong interpersonal skills, high level of professionalism, integrity and ethics in performance of all duties
• Excellent problem…