Investigator, Special Investigations Unit; Meritain Health

SIU Investigator

• Must be flexible to work EDT hours (8:00 am - 5 pm EDT).
• Conducts investigations to effectively pursue the prevention, investigation, and prosecution of healthcare fraud and abuse, in order to recover lost funds, as well as to comply with state regulations mandating fraud plans and practices.
• Conducts investigations of known or suspected acts of healthcare fraud and abuse.
• Communicates with federal, state, and local law enforcement agencies as appropriate in matters pertaining to the prosecution of specific healthcare fraud cases.
• Investigates to prevent payment of fraudulent claims committed by insured's, providers, claimants, customer members, etc.
• Facilitates the recovery of company and customer money lost as a result of fraud matters.
• Provides input regarding controls for monitoring fraud related issues within the business units.
• Delivers educational programs designed to promote deterrence and detection of fraud and minimize losses to the company.
• Maintains open communication with constituents internal and external to the company.
• Uses available resources and technology in developing evidence, supporting allegations of fraud and abuse.
• Researches and prepares cases for clinical and legal review.
• Documents all appropriate case activity in tracking system.
• Makes referrals and deconflictions, both internal and external, in the required timeframe.
• Cost effectively manages use of outside resources and vendors to perform activities necessary for investigations.

• 3+ years of experience working in fraud, waste and abuse investigations and audits.
• 3+ years of experience in healthcare/medical insurance claims investigation or professional/clinical experience.
• Demonstrated proficiency in Microsoft Office Suite (including Excel, specifically with pivot tables), database search tools, and use of the Intranet/Internet to research information.

• Strong analytical and research skills.
• Strong verbal and written communication skills.
• Strong customer service skills.
• Previous experience as a senior investigator.
• Previous experience utilizing Quick Base.
• Proficient in researching information and identifying information resources.
• Ability to utilize company systems to obtain relevant electronic documentation.
• Ability to travel and participate in legal proceedings, arbitrations, depositions, etc.
• Ability to interact with different groups of people at different levels and aid on a timely basis.
• Previous experience working with a Third-Party Administrator (TPA) and/or Self-Funded Plans in an investigative capacity.
• AHFI (Accredited Health Care Fraud Investigator), CFE (Certified Fraud Examiner), and/or CPC (Certified Professional Coder).
• Knowledge of CVS/Aetna/Meritain Health's policies and procedures.

• Bachelor's Degree or equivalent work experience (high school diploma or GED + 4 years of relevant work experience).

Anticipated Weekly

Hours:

40

Time Type: Full time

Pay Range:

$46,988.00 - $

Great benefits for great people

We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.

This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.

Additional details about available benefits are provided during the application process and on Benefits Moments.

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.