SIU Investigator - Lead

Medica•Minnetonka, MN

3h•$70,200 - $120,400•Onsite

About The Position

The SIU Investigator IV leads advanced investigations into suspected fraud, waste, and abuse involving members, providers, and employees. The role manages complex cases, conducts specialized audits, and evaluates evidence that informs organizational, regulatory, and legal actions. It provides subject matter expertise, guides investigative approaches, and ensures SIU processes align with legal and compliance standards. This position has significant influence on investigative outcomes and supports team success through expert consultation and direction. Performs other duties as assigned.

Requirements

Bachelor's degree or equivalent experience in related field
7+ years of previous investigative work experience beyond degree

Nice To Haves

Health Care Anti-Fraud Associate (HCAFA)
Accredited Health Care Fraud Investigator (AHFI)
Certified Fraud Examiner (CFE)
Healthcare, health plan or provider SIU experience required
Proven investigatory skill; ability to organize, analyze, and effectively determine risk with corresponding solutions; ability to remain objective and separate facts from opinions
Knowledge of Managed Care and the Medicaid and Medicare programs as well as Marketplace
Fundamental understanding of audits and corrective actions
Understanding of claim billing codes, medical terminology, anatomy, and health care delivery systems
Effective interpersonal skills and customer service focus; ability to interact with individuals at all levels
Excellent oral and written communication skills; presentation skills with ability to create and deliver training, informational and other types of programs
Advanced skills in Microsoft Office (Word, Excel, PowerPoint, Outlook), SharePoint and Intra/Internet as well as proficiency with incorporating/merging documents from various applications
Ability to multi-task and operate effectively across geographic and functional boundaries
Initiative, excellent follow-through, persistence in locating and securing needed information
Strong logical, analytical, critical thinking and problem-solving skills
Proven ability to research and interpret regulatory requirements
Understanding of datamining and use of data analytics to detect fraud, waste, and abuse
Detail-oriented, self-motivated, able to meet tight deadlines

Responsibilities

Lead Complex Fraud, Waste, and Abuse Investigations: Direct investigative activities involving complex or high‑risk cases. Evaluate evidence from claims data, medical records, interviews, and external sources. Develop investigative conclusions and recommendations that support legal or administrative action. Prepare detailed case summaries that document findings, rationale, and next steps.
Conduct Onsite Audits & Provider Reviews: Plan and conduct onsite audits to assess compliance with billing, clinical, or operational standards. Analyze provider documentation and practices to identify irregularities or patterns of concern. Present audit results to stakeholders and recommend corrective actions. Maintain accurate, comprehensive documentation to support case continuity and regulatory needs.
Serve as a SME with Legal, Regulatory, & Law Enforcement Partners: Collaborate with internal legal counsel on case strategies and regulatory considerations. Provide expert insights and case information to law enforcement and regulatory agencies. Represent SIU in external meetings, inquiries, or collaborative investigations. Respond to complex information requests with accuracy and timeliness.
Guide SIU Investigative Processes & Contribute to Program Oversight: Provide direction to team members on investigative methods, documentation standards, and case strategy. Identify process improvements that strengthen SIU effectiveness and compliance. Monitor investigative trends and risks to inform program planning and prevention efforts. Support development and adherence to SIU policies, procedures, and regulatory requirements.
Support Knowledge Sharing & Capability Development within the SIU: Mentor less experienced investigators on case management and investigative techniques. Share expertise on emerging fraud schemes, regulatory issues, and investigative best practices. Assist with training or education efforts for internal partners. Promote collaboration across the SIU to support consistent, high‑quality investigative work.