Special Investigative Unit Investigator

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This range is provided by Meta Sense Inc. Your actual pay will be based on your skills and experience — talk with your recruiter to learn more.

$20.99/hr – $20.99/hr

Position is remote but candidates must be in Eastern or Central time zones.

• Bachelors Degree (Masters or Law degree preferred), CFE or AHFI certification
• Minimum of 3 years experience in healthcare, pharmacy technician, claims adjudication, medical billing/coding, nursing or law enforcement
• Previous Experience Working For a Health Insurance Payer
• Minimum of 2 years experience conducting comprehensive investigations preferably with interaction with state, federal and local law enforcement agencies
• Previous Experience With FACETs System

Special Investigative Unit (SIU) Investigator responsible for investigating reports of non‑compliance with corporate and regulatory policies, including reports of fraud, waste, or abuse. As a member of the SIU team, the investigator recommends methodologies which help prevent improper conduct by identifying, assessing, and correcting areas of noncompliance in risk areas in an effective manner. Utilize monitoring systems to track, remediate and create reports particularly from the data mining tool.

Be responsible for all assigned investigations, follow‑ups, and resolutions. Possess the judgement and discretion to handle cases that are sensitive and/or high profile, and the intellectual rigor and professional experience to work on complex cases that can be national in scope and involve intricate health care fraud schemes.

• Independently analyze public and HAP internal data and information to develop preliminary assessment of facts to determine if full investigation is warranted. Develop investigative strategy and approach to complete investigation.
• Assembles evidence and documentation to support successful adjudication, where appropriate.
• Conduct on‑site audits of provider records ensuring appropriateness of billing practices.
• Conduct interviews with providers, employees, members, and witnesses as part of the investigative process.
• Prepare complex investigative and audit reports with the ability to present investigation summaries that include metrics, trends, and schemes to various stakeholders, including enforcement agencies.
• Craft a well organized referral explaining the alleged fraud in a fraud referral to regulators.
• Coordinate investigation with law enforcement authorities and regulatory agencies.
• Understand department, segment, and organizational strategy and operating objectives, including their linkages to related areas.
• Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed.
• Follow established guidelines/procedures.
• Ensure compliance department meets the required OIG effective compliance program elements by promptly responding to identified issues and concerns within the organization.
• Work independently and manage a caseload which includes investigations, identifying schemes, tracking, trending, and reporting instances of non‑compliance.
• Respond to alleged violations of rules, regulations, policies, procedures, and Code of Conduct by evaluating or recommending the initiation of investigative procedures. Ensure policies and procedures are followed for the general operation of the compliance program and its related activities to prevent illegal, unethical, or improper conduct.
• Independently move a case to the next step in the investigative process with minimal assistance and errors. Includes from the opening to final disposition.
• Independently develop new cases based on proactive data mining efforts.
• Respond to a complaint, take statements, document effectively and identify any fraud, waste or abuse.
• Identify patterns and trends to generate new investigative leads.
• Demonstrate strong teamwork and collaboration, effectively working with other investigators to achieve common goals and take responsibility for team…