Lead Investigator, Special Investigative Unit-(kentucky

JOB DESCRIPTION Job Summary

Under direct supervision of the Manager, SIU, the Team Lead is responsible to lead a small team of investigators and provide oversight on daily investigative activities as a back‑up to the SIU Manager. This position will be accountable for tracking investigations conducted by his/her team and will provide oversight and guidance throughout the life of an investigation as well as QA reviews and approvals.

In addition to leading a team of investigators and analysts, the Team Lead will ensure the Manager is aware of any major case developments and ensure cases are being investigated according to the SIU’s standards. Position must have thorough knowledge of Medicaid/Medicare/Marketplace health coverage audit policies and be able to apply them in ensuring program compliance via payment integrity programs.

The position must have the ability to determine correct coding, documentation, potential fraud, abuse, and over‑utilization by providers and recipients. The position will review claims data, medical records, and billing data from all types of healthcare providers that bill Medicaid/Medicare/Marketplace.

• Ensure investigators are managing their cases effectively and in accordance with SIU policies, processes, quality standards, and procedures.
• Ensure that investigators are managing their respective State Reporting requirements and assignments effectively and timely.
• Manage the flow of day‑to‑day investigations.
• Perform assessment that QA measures were complete and signed‑off.
• Provide guidance to investigators as needed on investigative techniques, tools, or strategy.
• Effectively investigate and manage complex and non‑complex fraud allegations.
• Develop and maintain relationships with key business units within specific product line and geographic region.
• Provides direction, instructions, and guidance to Investigative team, particularly in the absence of the SIU Manager.
• Provide training to team members as needed.
• Communicate clear instructions to team members, listen to team members’ feedback.
• Monitor team members’ participation to ensure the training provided is effective, and if any additional training is needed.
• Create, edit, and update assigned reports to apprise the company on the team's progress.
• Distribute reports to the appropriate personnel.

• High School/GED
• Associates degree or bachelor’s degree in Health Information Management, Health Care Administration, Finance, Criminal Justice, Law Enforcement, or related field (applicable FWA experience would be accepted in lieu of education experience).

• Associates degree or bachelor’s degree in Health Information Management, Health Care Administration, Finance, Criminal Justice, Law Enforcement, or related field (applicable FWA experience would be accepted in lieu of education experience).
• At least five (5) years’ experience working in a Managed Care Organization or health insurance company.
• Minimum of two (2) years’ experience working on healthcare fraud related investigations/reviews.
• 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 investigative and law enforcement procedures with emphasis on fraud investigations.
• Knowledge of Managed Care and the Medicaid and Medicare programs as well as Marketplace.
• Understanding of claim billing codes, medical terminology, anatomy, and health care delivery systems.
• Understanding of data mining and use of data analytics to detect fraud, waste, and abuse.
• Proven ability to research and interpret regulatory requirements.
• 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 Intranet as well as proficiency with incorporating/merging documents from various applications.
• Strong logical,…