SIU Investigator
About The Position
Investigate allegations of potential healthcare fraud and abuse activity. Assist in planning, organizing, and executing claims investigations or audits that identify, evaluate and measure potential healthcare fraud and abuse. Conduct investigations of potential waste, abuse, and fraud Document activity on each case and refer issues to the appropriate party Perform data mining and analysis to detect aberrancies and outliers in claims Develop new queries and reports to detect potential waste, abuse, and fraud Provide case updates on progress of investigations and coordinate with Health Plans on recommendations and further actions and/or resolutions Assist with complex allegations of healthcare fraud Prepare summary and/or detailed reports on investigative findings for referral to Federal and State agencies Complete various special projects and audits Performs other duties as assigned Complies with all policies and standards
Requirements
- Bachelor's Degree Business, Criminal Justice, Healthcare, or related field, or equivalent experience required
- 1+ years Medical claim investigation, medical claim audit, medical claim analysis, or fraud investigation required
Responsibilities
- Investigate allegations of potential healthcare fraud and abuse activity.
- Assist in planning, organizing, and executing claims investigations or audits that identify, evaluate and measure potential healthcare fraud and abuse.
- Conduct investigations of potential waste, abuse, and fraud.
- Document activity on each case and refer issues to the appropriate party.
- Perform data mining and analysis to detect aberrancies and outliers in claims.
- Develop new queries and reports to detect potential waste, abuse, and fraud.
- Provide case updates on progress of investigations and coordinate with Health Plans on recommendations and further actions and/or resolutions.
- Assist with complex allegations of healthcare fraud.
- Prepare summary and/or detailed reports on investigative findings for referral to Federal and State agencies.
- Complete various special projects and audits.
- Performs other duties as assigned.
- Complies with all policies and standards.
Benefits
- competitive pay
- health insurance
- 401K
- stock purchase plans
- tuition reimbursement
- paid time off
- holidays
- flexible approach to work with remote, hybrid, field or office work schedules
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
