REMOTE - SIU Investigator Lead; live in OH or states - R12911-2

Job Summary

The Special Investigations Unit (SIU) Investigator Lead serves as the primary representative of the SIU to external federal and state regulatory agencies. The role is responsible for regulatory communications to ensure timely compliance with oversight agencies, identify and monitor emerging fraud, waste, and abuse (FWA) trends, and conduct research on claims and other data sources to support ongoing fraud investigations. The Investigator Lead utilizes various data analytics platforms to mine large volumes of data, identify and mitigate fraudulent claim activity, and discover patterns and anomalies in billing behavior.

• Identify risks and guard against fraud, waste, and abuse by interacting with internal and external business partners through development and monitoring of the Annual Program Integrity Fraud, Waste and Abuse Plan.
• Develop and implement innovative best practices to align with future growth and ongoing regulatory oversight.
• Act as the Program Integrity liaison and ensure collaboration with state and federal agencies, facilitating accurate deployment and ongoing monitoring of state-specific regulations and partnership with state regulators in managing Medicaid and Medicare programs.
• Engage in external fraud associations, forming relationships with industry leads (i.e., other MCEs, NHCAA, etc.).
• Predict emerging fraud, waste and abuse trends and communicate strategy to monitor and identify risk to Care Source.
• Identify opportunities for cost avoidance through prepayment review, provider education, or other preventative measures.
• Responsible for regulatory reporting accuracy and other ad‑hoc regulatory inquiries.
• Ensure the team submits a consistent high volume of quality FWA referrals to state partners.
• Lead investigations on‑site and serve as a mentor for the team.
• Conduct and assist investigators with complex investigations.
• Collaborate with the data analytics team and utilize RAT STATS on Statistically Valid Random Sampling.
• Manage case turnaround times to promote efficiency in investigations and mitigate risk to Care Source.
• Meet quality standards of case documentation.
• Generate leads in the fraud detection system to result in investigations that will prevent risk to Care Source. Trend data to identify potential opportunities (e.g., variances, significant outliers, percentile‑ranked groups) for quality improvement or focused investigations.
• Identify trends and patterns using standard corporate processes, tools, reports, and databases, and leverage other processes and data sources such as policies, coding guidelines, and regulations that support the hypothesis being developed.
• Manage and decide on 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 plans.
• Execute and manage provider formal corrective action plans.
• Participate in meetings with operational departments, business partners, and regulatory partners to facilitate investigative case development.
• Collaborate 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.
• Aid in designing data analysis strategies to identify potential areas for quality improvement or focused investigation.
• Monitor various media, state and federal press releases to identify emerging schemes and potential impact or exposure.
• Lead and participate in all information‑sharing activities and produce actionable data analyses from information obtained.
• Manage and maintain sensitive confidential investigative information.
• Maintain compliance with state and federal laws, 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 Fraud & Abuse Investigations required.
• Master’s…