SIU Investigator

Martin's Point Health Care•Portland, ME

About The Position

The SIU Investigator investigates suspected fraud, waste, and abuse (FWA) involving providers, suppliers, members, and other entities across Martin’s Point’s Generations Advantage and US Family Health Plan (TRICARE) health plans. Reporting to the Director, Special Investigations Unit (SIU), the Investigator manages cases from intake through resolution, including data analysis, medical record review, interviews, overpayment recovery, and referrals to federal oversight entities and law enforcement. As an early member of a newly established SIU, the Investigator will help develop investigative standards, procedures, and cross-functional workflows. The role supports the organization’s FWA compliance obligations under its Medicare Advantage and USFHP contracts. It also involves maintaining accurate case records and contributing to SIU reporting on recoveries, cost avoidance, and referrals using NHCAA-aligned measures. The position requires independent work and the ability to contribute in a growing department where procedures are still being developed. Martin’s Point Health Care is a not-for-profit health care organization serving Maine and beyond. The organization describes its culture as one of trust and respect, grounded in taking care of others, continuous learning, helping each other, and having fun.

Requirements

At least five years of experience in health care fraud investigation, SIU, payment integrity, program integrity, or law enforcement health care fraud work.
Medicare Advantage experience.
Bachelor’s degree in criminal justice, health care administration, accounting, or another related field, or an equivalent combination of education and experience.
Working knowledge of Medicare Advantage program integrity requirements, the False Claims Act, the Anti-Kickback Statute, the Stark Law, and overpayment reporting obligations.
Strong command of CMS-1500 and UB-04 claim formats and coding conventions.
Ability to produce investigative writing that can withstand legal and regulatory scrutiny.
Interviewing skills, sound judgment, discretion, and rigorous handling of protected health information (PHI).
Ability to work independently and contribute in a start-up environment where SIU procedures are still being built.
Understanding of and alignment with Martin’s Point Values.

Nice To Haves

At least one of the following certifications: AHFI, CFE, CPC, CCS, or CPMA.
TRICARE or other government program experience.
Advanced Excel skills, SQL, PowerBI, or similar tools.

Responsibilities

Investigate suspected FWA cases from intake through resolution, including referrals from internal departments, the compliance hotline, and external sources.
Develop a plan for each case that defines the allegation, scope, and estimated financial exposure.
Analyze claims data to identify unusual billing patterns, estimate potential overpayments, and support statistically valid sampling and extrapolation when appropriate.
Review medical records and supporting documentation against CMS and TRICARE requirements, Martin’s Point payment policies, CPT, HCPCS, and ICD-10-CM coding guidelines, and applicable National and Local Coverage Determinations.
Coordinate clinical and coding reviews with internal departments as needed.
Conduct member and provider outreach, including investigative interviews.
Maintain thorough, well-documented case files.
Draft findings letters and overpayment determinations, and recommend corrective actions such as provider education, prepayment review, recoupment, and network action.
Prepare referrals to the CMS Investigations MEDIC, the Defense Health Agency Program Integrity Office, HHS-OIG, and law enforcement within required timeframes.
Respond to information requests from oversight entities and law enforcement.
Maintain accurate case management records and contribute to SIU reporting on recoveries, cost avoidance, and referrals using NHCAA-aligned measures.
Track emerging fraud schemes and develop, recommend, and assist in developing new analytics and edits.
Support FWA compliance obligations under Medicare Advantage and USFHP contracts, including contributing to FWA training content.
Demonstrate the organization’s mission, vision, and core values through consistent work.