SIU Coding Investigator

Position Purpose: The Special Investigations Unit (SIU) Investigator is responsible for analyzing, planning, and investigating suspicious claims and potential fraud, and conducting background investigations. Furthermore, this role will be tasked with partnering with multiple business units to design and execute plans of action to investigate suspicious matters, trends, and activities and will conduct investigations through the use of in-house investigative tools, outside investigative services, industry associations, and the government agencies.

Primary Responsibilities:

• Reviews suspicious matters, creates plan of action, and accelerates appropriate resolution of referred matters.
• Partners with multiple business units on matters of moderate-to-severe exposure.
• Conducts field investigative activities.
• Interviews all parties attendant to a given matter.
• Investigates allegations and complex issues pertaining to potential health care fraud, waste, or abuse by providers, pharmacies, patients/members, or other entities.
• Performs data mining and analyses to detect aberrancies/outliers in claims and other data in order to proactively detect and report fraud, waste, and abuse.
• Writes comprehensive investigatory fact-finding reports and summaries documenting interviews and findings.
• Compiles and maintains various documentation and other reporting requirements as needed.
• Facilitates the recovery of monies lost as a result of fraud, waste, and abuse matters.
• Develops and maintains strong working relationships with associates and regulators including Medicaid, Medicare, DOJ, OIG, etc.
• Other duties as assigned.

Education:

High School Diploma/GED required. Bachelor's degree in healthcare-related field preferred Preferred.

Years of Experience:

• Coding/Auditing: 1-3 Years
• Claims/Policies & Procedures: 3-5 Years
• Legal/Compliance/Special investigations: 3-5 Years

Specialized Knowledge:

• Turning data into Information / advanced data analysis.
• Strong analytical and research skills. Proficient in researching information and identifying information resources.
• Strong verbal and written communication skills.
• Ability to interact with different groups of people at various levels and to provide assistance on a timely basis.
• Proficiency in Word, Excel, MS Outlook, database search tools, and use of Internet to research information.