SIU Auditor

Amerihealth Caritas•,

2d•Remote

About The Position

The SIU Auditor is responsible for conducting comprehensive investigations of reported, alleged or suspected fraud involving the full range of products at the AmeriHealth Caritas Family of Companies (ACFC). This role is remote within the United States with Delaware residency preferred. For roles that are 100% remote or hybrid, you must have access to a reliable high-speed internet connection to support daily job responsibilities. A minimum bandwidth of 50 Mbps download and 5 Mbps upload is required. Those fully remote associates residing in states where service is required by contract, law, or regulation will be allowed to submit for reimbursement.

Requirements

1+ years of Auditing experience or related experience in healthcare.
Valid driver’s license required.
Strong verbal and written communication skills.
Working knowledge of Microsoft applications, especially Excel required.
Analytical skills and ability to make deductions; logical and sequential thinker.
Solid knowledge of Medicaid, Medicare, and pharmacy benefit laws and requirements; federal, state, civil and criminal statutes.
Experience with decision support tools used for data analysis.
Advanced knowledge and experience working on various approaches to fraud, waste and abuse.

Nice To Haves

Bachelor’s Degree preferred or equivalent work experience in healthcare-related fields.
Medicaid experience preferred.
SIU and/or State Medicaid regulatory compliance work experience a plus.
Knowledge and proficiency in claims adjudication standards & procedures preferred.
Experience with Medicaid, Medicare, and/or pharmacy benefit reimbursement. Specific experience required driven by business needs.
Experience with LTSS preferred.

Responsibilities

Ensures compliance with all requirements related to Special Investigation Units and fraud, waste and abuse investigations.
Conducts comprehensive interviews with providers, members and witnesses to obtain information which would be considered admissible under generally accepted criminal and civil rules of evidence.
Proactively performs research using the Internet, data analysis tools, etc., to analyze aberrant claims billing and practice patterns.
Conducts proactive data mining and analyzes data as part of the investigative process using available fraud detection software and corporate resources.
Prepares and submits investigative reports covering all phases of the investigation.
Interprets and conveys highly technical information to others.
Establishes and maintains liaison with public officials, law enforcement and others to obtain assistance in conducting investigations.
Knowledge of available resources (internal and external) to assist in investigations.