SIU Investigator

Job Description A bit about this role: Are you a highly analytical and experienced investigator with a passion for uncovering the truth and protecting vital healthcare resources? Our Special Investigations Unit (SIU) is looking for a skilled Investigator to join our dedicated team. In this crucial role, you'll be at the forefront of preventing, detecting, and responding to healthcare fraud, waste, and abuse (FWA), safeguarding our members and the integrity of the Medicare Fund. If you're driven by meticulous investigation, data-driven insights, and a commitment to justice, we encourage you to apply . Responsibilities and Impact will include: As an SIU Investigator, you'll be responsible for the full lifecycle of complex FWA investigations, acting as a subject matter expert and collaborating with various stakeholders. Your key responsibilities will include: Lead Complex Investigations: Plan, organize, and execute specialized investigations into allegations of healthcare fraud, waste, and abuse. This includes handling intricate cases requiring advanced investigative knowledge and skills . Data-Driven Detection: Utilize advanced data mining and analysis techniques to identify aberrancies and outliers in claims, medical records, enrollment, and other healthcare transactions. You'll independently research FWA issues and employ cutting-edge investigative resources. Expert Guidance: Serve as a subject matter expert for other SIU Investigators, providing specialized knowledge and guidance to elevate team capabilities. Policy & Strategy Development: Contribute to the development of robust policies and procedures related to FWA detection and investigation, as well as the annual SIU risk assessment and work plan . Thorough Documentation & Reporting: Conduct comprehensive FWA investigations, ensuring complete and accurate case documentation and detailed investigative reports that adhere to SIU policies and standards. External Referrals & Collaboration: Prepare comprehensive summary and detailed reports on investigative findings for referral to federal and state agencies, ensuring full compliance with regulatory requirements. You'll also actively participate in OIG Healthcare Fraud Workgroups. Stakeholder Engagement: Collaborate closely with internal stakeholders (e.g., FWA Monthly Workgroup, Market/Network, Credentialing Committee) to share updates on FWA schemes, coordinate recommendations, and facilitate fund recovery or other necessary actions. Provider Education: Conduct impactful provider education sessions as a direct response to investigation findings and audits. Liaison & Point of Contact: Serve as a key point of contact for corporate and field inquiries regarding FWA, and participate in meetings with providers, business partners, regulatory agencies, and law enforcement. Training & Development: Assist in developing and presenting engaging FWA training programs for internal and external audiences. Required skills and experience: Education: A Bachelor’s Degree in Business, Criminal Justice, Healthcare, or a related field, or equivalent relevant work experience. Experience:Minimum of 3 years of dedicated experience in health insurance fraud investigation. Proven experience within Medicare and/or Medicaid programs , specifically with medical claim billing, reimbursement, audit, or provider contracting. Demonstrated experience with data analysis techniques . Experience with the Healthcare Fraud Shield platform is a significant plus. Exceptional Analytical Skills: Ability to interpret and dissect complex data sets, identifying patterns and anomalies indicative of FWA. Must have demonstrated experience with AI tools . Outstanding Communication: Excellent written and verbal communication skills are essential for clear report writing, compelling presentations, and effective stakeholder engagement. Integrity & Detail-Oriented: A strong commitment to integrity and compliance, coupled with meticulous attention to detail in all aspects of investigations. Independent & Collaborative: Proven ability to work independently, manage a diverse caseload of investigations, and thrive in a fast-paced environment, while also excelling in collaborative team settings. Strong Organizational Skills: Highly organized with the ability to manage multiple complex investigations simultaneously and effectively prioritize tasks. Desired skills and experience: Certified Fraud Examiner (CFE) Certified Professional Coder (CPC) #LI-DS1 #LI-Remote Salary range: $58,000 - $90,000 /year The pay range listed for this position is the range the organization reasonably and in good faith expects to pay for this position at the time of the posting. Once the interview process begins, your talent partner will provide additional information on the compensation for the role, along with additional information on our total rewards package. The actual base salary offered will depend on a variety of factors, including the qualifications of the individual applicant for the position, years of relevant experience, specific and unique skills, level of education attained, certifications or other professional licenses held, and the location in which the applicant lives and/or from which they will be performing the job. Our Total Rewards package includes: Employer sponsored health, dental and vision plan with low or no premium Generous paid time off $100 monthly mobile or internet stipend Stock options for all employees Bonus eligibility for all roles excluding Director and above; Commission eligibility for Sales roles Parental leave program 401K program And more.... *Our total rewards package is for full time employees only. Intern and Contract positions are not eligible. Healthcare equality is at the center of Devoted’s mission to treat our members like family.  We are committed to a diverse and vibrant workforce.  At Devoted Health, we’re