Special Investigative Unit Investigator

Troy, Michigan
Special Investigative Unit Investigator #1044197

• Investigate reports of non‑compliance with corporate and regulatory policies, including fraud, waste, or abuse.
• Recommend methodologies to prevent improper conduct by identifying, assessing, and correcting non‑compliance in risk areas.
• Utilize monitoring systems and data‑mining tools to track, remediate, and produce reports.
• Handle all assigned investigations, follow‑ups, and resolutions.
• Maintain judgement and discretion for sensitive or high‑profile cases, with intellectual rigor for complex, national‑scope fraud schemes.

• Analyze public and internal data to determine if a full investigation is warranted and develop investigative strategy.
• Collect evidence and documentation for adjudication.
• Conduct on‑site audits of provider records to ensure billing appropriateness.
• Interview providers, employees, members, and witnesses.
• Prepare complex investigative and audit reports, presenting metrics, trends, and schemes to stakeholders, including enforcement agencies.
• Craft well‑organized referrals explaining alleged fraud to regulators.
• Coordinate investigations with law enforcement and regulatory agencies.
• Understand organizational strategy and its linkages to related areas.
• Make independent decisions about investigative methods with minimal direction.
• Follow established guidelines and procedures.
• Ensure compliance program meets OIG effective compliance program elements.
• Manage a caseload of investigations, identifying schemes, tracking trends, and reporting non‑compliance.
• Respond to alleged violations, evaluating or recommending investigative procedures.
• Progress investigations from opening to final disposition with minimal assistance.
• Develop new cases based on proactive data mining.
• Respond to complaints, take statements, and document potential fraud, waste, or abuse.
• Identify patterns and trends to generate new investigative leads.
• Demonstrate teamwork and collaboration with other investigators.
• Show adaptability in taking on varied investigative responsibilities.
• Demonstrate experience with Medicare, Medicaid, ACA, and commercial managed care products.
• Develop and facilitate training on Fraud, Waste, Abuse, HFH Non‑retaliation policy, Code of Conduct, and government program requirements.
• Perform related duties as assigned.

• Experience with RATSTATS or similar sampling programs.
• Proficient in Excel for large data analysis, visualization, and automation (macros, pivot tables, Power Query).
• Experience with Microsoft Power BI; knowledge of SQL preferred.
• Excellent verbal, written, and presentation skills.
• Ability to work with diverse backgrounds at all levels.
• Objective, creative analytical and auditing skills.
• Knowledge of health‑care industry product lines and payment methodologies.
• Experience with FACETs or similar claim systems.
• Strong personal and professional ethics.

• Communication
• Understanding
• Sensitivity
• Teamwork

• Self‑directed
• Flexible and committed to the team concept
• Initiative and willingness to learn
• Open to new learning experiences
• Respectful of diversity without judgment
• Demonstrated customer service values

• Normal office environment with minimal exposure to noise, dust, or extreme temperatures.
• Sedentary work; occasional lifting of up to 10 lbs of force.
• Requires sitting most of the time; occasional walking or standing.
• Verbal communication required.
• Hearing required.

• Medical and Dental (majority paid by Fast Tek)
• Vision
• Personal Time Off (PTO) program
• Long‑Term Disability (100% paid)
• Life Insurance (100% paid)
• 401(k) with immediate vesting and 3% salary match