SIU Investigator III (Must live in Arkansas)

CareSource•Arkansas WFH, AR

9d•$64,980 - $103,950

About The Position

The SIU Investigator III investigates and resolves high-complexity allegations of healthcare fraud, waste, and abuse involving medical professionals, facilities, and members. The role researches, gathers, and analyzes data to identify trends, patterns, aberrancies, and outliers in provider billing behavior, and serves as a subject matter expert for other investigators. This position develops and manages strategic, fact-driven investigations, including business process reviews, investigative activities, data reports, audits, interviews, and recommendations. It works with analytics, legal, operational, business, regulatory, and law-enforcement partners to develop cases, pursue corrective actions and recoveries, support litigation and regulatory reporting, and maintain compliance with applicable laws, regulations, and contracts. The role requires a working knowledge of healthcare billing and coding, medical standards, and state and federal program rules. The position is for candidates who must live in Arkansas.

Requirements

Bachelor’s degree or equivalent years of relevant work experience in a health-related field, law enforcement, or insurance.
At least five years of experience in healthcare fraud investigations, medical coding, pharmacy, medical research, auditing, data analytics, or a related field.
Accredited Healthcare Fraud Investigator (AHFI) or Certified Fraud Examiner (CFE) certification.
Intermediate proficiency in Microsoft Office, including Outlook, Word, Excel, Access, and PowerPoint.
Effective listening and critical-thinking skills, including the ability to identify gaps in logic.
Strong interpersonal skills and a high level of professionalism, integrity, and ethics.
Excellent problem-solving and decision-making skills, with attention to detail.
Research background and ability to draw conclusions.
Ability to perform intermediate data analysis and articulate an understanding of findings.
Ability to work under limited supervision with moderate latitude for initiative and independent judgment.
Ability to manage a demanding investigative caseload.
Ability to develop, prioritize, and accomplish goals.
Self-motivated and self-directed.
Strong writing skills, including the ability to prepare detailed investigative reports and professional internal and external correspondence.
Leadership qualities.
Must live in Arkansas.

Nice To Haves

Master’s degree, such as in criminal justice, public health, mathematics, statistics, health economics, or nursing.
Presentation experience.
Knowledge of Medicaid, Medicare, and healthcare rules.
Background in medical terminology, CPT, HCPCS, ICD codes, or medical billing.
Complex project management skills.
Certified Professional Coder (CPC) certification.
NHCAA or other fraud and abuse investigation training.

Responsibilities

Develop, coordinate, and conduct strategic, fact-driven investigative projects, including business process reviews, investigative activities, and outcome recommendations.
Manage the development, production, and validation of reports using claims, eligibility, pharmacy, and clinical data, and translate findings into actionable items.
Manage the strategic investigative plan and drive investigative outcomes for the team.
Ensure quality outcomes for the investigative team through auditing and oversight.
Prioritize, track, and report investigation status.
Report identified corporate financial impact issues.
Analyze complex provider claim submissions using coding guidelines.
Research and interpret state-specific Medicaid, federal Medicare, and ACA/Exchange laws, rules, and guidelines.
Research medical standards and authoritative healthcare sources and apply them to investigative approaches.
Collaborate with the data analytics team and use RAT STATS for statistically valid random sampling.
Coordinate and conduct on-site and desk audits of medical records and claims.
Manage and make decisions on claims pended for investigative purposes.
Maintain working knowledge of applicable state and federal laws, rules, and billing guidelines for provider specialty types.
Prepare and conduct in-depth, complex interviews relevant to investigative plans.
Execute and manage formal provider corrective action plans.
Participate in meetings with operational departments, business partners, and regulatory partners to facilitate case development.
Work with Legal General Counsel on legal actions, corrective actions, negotiations, recovery efforts, settlement agreements, and evidentiary documents for litigation.
Present, support, and defend investigative research to seek approval for formal corrective actions.
Establish and maintain relationships with federal and state law enforcement agencies, task force members, company SIU staff, and other external contacts involved in fraud investigation, detection, and prevention.
Serve as a subject matter expert in the designated market and apply external intelligence to analysis and case development.
Develop and deliver internal and external formal presentations as needed.
Attend fraud, waste, and abuse training or conferences as needed.
Support regulatory fraud, waste, and abuse reports to federal and state Medicare and Medicaid agencies.
Manage and maintain sensitive, confidential investigative information.
Maintain compliance with state and federal laws, regulations, and contracts; adhere to the CareSource Corporate Compliance Plan and Anti-Fraud Plan.
Assist with federal and state regulatory audits as needed.
Perform other job-related instructions as requested.