Investigator II

Job Summary

The Investigator II is an essential team member of the Special Investigation Unit (SIU) responsible for leading complex provider investigations related to fraud, waste, and abuse, and developing action plans to address the investigative findings and prevent future loss. The Investigator works closely with other members of the SIU to set investigative priorities, develop effective investigative strategies and techniques, and recommend measures to address new and evolving schemes.

Key Responsibilities/Duties – what you will be doing (top five):

• Lead moderately complex to complex investigations in established and emerging areas of Fraud Waste and Abuse (FWA) involving internal and external research, detailed data analyses, review of medical records, and interviews of members, providers, and other third parties.
• Apply laws, regulations, plan policies and guidelines, contract provisions, coding rules, coverage rules, and industry standards to information gathered during the investigation.
• Complete detailed reports of investigative activity and prepare summary findings notices for providers or other entities.
• Work with SIU management to educate providers, recover over payments, take action to prevent future loss, and monitor provider activity post-investigation.
• Identify root causes of fraud, waste and abuse and recommend internal and external corrective actions to address these root causes.
• Develop new investigations based upon case findings.
• Recommend investigative priorities, strategies, and techniques.
• Work with the analytics and intake team to develop and refine data mining to address new and evolving schemes.
• Share expertise and promote investigative best practices among SIU management and staff.
• Educate and collaborate with various business units to raise awareness of potential FWA concerns.
• Perform out-of-the-box thinking, collaborate with others, and make a difference every day!
• Other duties and projects as assigned.

• Certified Professional Coder (“CPC”);
  Certified Fraud Examiner (“CFE”) designation a plus.

• Required (minimum):
  Bachelor’s degree
• Preferred:
  Degree preferably in a clinical or scientific field, business, accounting, computer science, or criminal justice.

• Required (minimum): 3‑5 years’ related experience in health insurance and/or fraud investigations.

Preferred:
Experience in audits/investigations including experience drafting and distributing summary findings notices to providers or other entities.

• Ability to produce clear, concise, and well-organized documents.
• Resilient, collaborative, flexible, innovative.

• Must be able to work under normal office conditions and work from home as required.
• May be required to attend meetings at other company locations or other external meetings.
• Work may require simultaneous use of a telephone/headset and PC/keyboard and sitting for extended durations.
• May be required to work additional hours beyond standard work schedule.

$80,741.22 – $

The annual base salary range provided for this position represents a range of salaries for this role and similar roles across the organization. The actual salary for this position will be determined by several factors, including the scope and complexity of the role; the skills, education, training, credentials, and experience of the candidate; as well as internal equity. As part of our comprehensive total rewards program, colleagues are also eligible for variable pay.

Eligibility for any bonus, commission, benefits, or any other form of compensation and benefits remains in the Company's sole discretion and may be modified at the Company’s sole discretion, consistent with the law.

• Medical, dental and vision coverage
• Retirement plans
• Paid time off
• Employer-paid life and disability insurance with additional buy-up coverage options
• Tuition program
• Well-being benefits
• Full suite of benefits to support career development, individual & family health, and financial health

For more details on our total…