Senior Investigator, Special Investigations Unit (SIU)
Core
Conduct high-level investigations of healthcare fraud and abuse, specifically targeting Medicaid lines of business to prevent fraudulent claim payments.
Role type
Senior IC healthcare fraud investigator
Builds
Fraud prevention controls and case files for legal review
Domain
Healthcare / Insurance Fraud
Deliverable
client delivery
Required skills
Healthcare claims analysis, Medical coding (CPT, HCPCS, ICD10), Data mining, Case documentation, Legal testimony, Money recovery
Preferred skills
Medicaid/Medicare investigatory experience, Behavioral Health experience, CFE or AHFI certification, Complex clinical issue knowledge, Legal theory knowledge
Technologies
Microsoft Excel (Pivot Tables)
Responsibilities
Investigate suspected healthcare fraud and abuse; Research and prepare cases for clinical and legal review; Document case activity in tracking systems; Facilitate feedback with providers; Initiate proactive data mining for aberrant billing patterns; Make internal and external referrals; Facilitate recovery of lost funds; Provide on-the-job training to new investigators; Cooperate with law enforcement agencies; Provide testimony in civil and criminal proceedings; Present to internal and external customers on fraud matters.
Seniority
Senior, hands-on IC
