SIU Investigator - Remote

Martin’s Point Health Care•Portland, ME

5d•$75,585 - $93,369•Remote

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). 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 shape investigative standards, procedures, and cross-functional workflows. The role supports the organization’s FWA compliance obligations under its Medicare Advantage and USFHP contracts. The Investigator is expected to demonstrate Martin’s Point’s mission, vision, and core values, and to work independently in a growing department where procedures are still being developed. The role offers a salary range of $75,584.55–$93,369.15 for a full-time position. Compensation within the range depends on factors including relevant experience, market conditions, internal equity, and budget. Employees may be eligible for additional compensation where applicable. The position is not eligible for immigration sponsorship.

Requirements

Bachelor’s degree in criminal justice, health care administration, accounting, or another related field, or an equivalent combination of education and experience.
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.
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.
Investigative writing skills sufficient to 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 procedures are still being developed.
Demonstrated 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 fraud, waste, and abuse cases from intake through resolution, developing a case plan that defines the allegation, scope, and estimated financial exposure.
Analyze claims data to identify unusual billing patterns, estimate overpayment exposure, 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, 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 timely referrals to the CMS Investigations MEDIC, the Defense Health Agency Program Integrity Office, HHS-OIG, and law enforcement, and respond to their requests for information.
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 recommendations for, and assist in developing, new analytics and edits.
Support FWA compliance obligations under Medicare Advantage and USFHP contracts, including contributing to FWA training content.