SIU Investigator II

Medica is a nonprofit health plan with more than a million members that serves communities in Minnesota, Nebraska, Wisconsin, Missouri, and beyond. We deliver personalized health care experiences and partner closely with providers to ensure members are genuinely cared for.

We're a team that owns our work with accountability, makes data-driven decisions, embraces continuous learning, and celebrates collaboration - because success is a team sport. It's our mission to be there in the moments that matter most for our members and employees. Join us in creating a community of connected care, where coordinated, quality service is the norm and every member feels valued.

The Special Investigation Unit (SIU) Investigator is responsible for supporting the prevention, detection, investigation, reporting, and when appropriate, recovery of money related to health care Fraud, Waste, and Abuse (FWA). The SIU Investigator is responsible for reviewing and analyzing information to draw conclusions on allegations of FWA. The position may also work with other internal departments, including Compliance, Legal, Payment Integrity and Medical Officers in order to achieve and maintain appropriate anti-fraud oversight.

Key Accountabilities:

• Responsible for triaging and developing leads presented to the SIU to assess and determine whether potential fraud, waste, or abuse is corroborated by evidence.
• Conducts both preliminary investigations of FWA allegations, and end to end full investigations, including but not limited to witness interviews, background checks, request and review medical records, data analytics etc
• Completes investigations within the mandated period of time required by state and federal regulations
• Coordinates with various internal customers (e.g., Provider Services, Contracting and Credentialing, Healthcare Services, Member Services, Claims) to gather documentation pertinent to investigations
• Prepares appropriate FWA referrals to regulatory agencies and law enforcement
• Documents appropriately all case related activities and evidence in the case management system, following SIU related requirements
• Renders provider education on appropriate practices (e.g., coding) as applicable based on national or local guidelines, contractual, and/or regulatory requirements
• Interacts with regulatory and/or law enforcement agencies regarding case investigations
• Prepares audit results letters to providers when over payments are identified
• Complies with SIU Policies and procedures as well as goals set by SIU leadership

Qualifications:

• Bachelor's degree or Associate's degree in criminal justice or relevant field, or equivalent work experience plus 3 years of work experience
• Healthcare, health plan or provider SIU experience required
• Proven investigatory skill; ability to organize, analyze, and effectively determine risk with corresponding solutions; ability to remain objective and separate facts from opinions
• Knowledge of Managed Care and the Medicaid and Medicare programs as well as Marketplace
• Fundamental understanding of audits and corrective actions
• Understanding of claim billing codes, medical terminology, anatomy, and health care delivery systems

Preferred Designations:

• Health Care Anti-Fraud Associate (HCAFA)
• Accredited Health Care Fraud Investigator (AHFI)
• Certified Fraud Examiner (CFE)

Skills and Abilities:

• Effective interpersonal skills and customer service focus; ability to interact with individuals at all levels
• Excellent oral and written communication skills; presentation skills with ability to create and deliver training, informational and other types of programs
• Advanced skills in Microsoft Office (Word, Excel, PowerPoint, Outlook), SharePoint and Intra/Internet as well as proficiency with incorporating/merging documents from various applications
• Ability to multi-task and operate effectively across geographic and functional boundaries
• Initiative, excellent follow-through, persistence in locating and securing needed information
• Strong logical, analytical, critical thinking and problem-solving skills
• Proven ability to research and interpret regulatory requirements
• Understanding of data mining and use of data analytics to detect fraud, waste, and abuse
• Detail-oriented, self-motivated, able to meet tight deadlines

This position is an Office role, which requires an employee to work onsite at our Minnetonka, MN office, on average, 3 days per week.

The full salary grade for this position is $50,800 - $87,000. While the full salary grade is provided, the typical hiring salary range for this role is expected to be between $50,800 - $76,125. Annual salary range placement will depend on a variety of factors including, but not limited to, education, work experience, applicable certifications and/or licensure, the position's scope and responsibility, internal pay equity and external market salary data.

In addition to compensation, Medica offers a generous total rewards package that includes competitive medical, dental, vision, PTO, Holidays, paid volunteer…