Job Description

We are seeking a detail-oriented SIU Investigator to join our team. In this role, you will play a crucial role in ensuring the accuracy, compliance, and integrity of healthcare claims through comprehensive audits, analyses, and process improvements. The SIU Investigator (Analyst) primary responsibility is to detect, investigate, and produce change in aberrant behavior observed in our healthcare customer's claims and enrollment data. You will work both independently and with a team of clinical SMEs to analyze data, assess exposure, and manage investigative caseload from identification through to resolution including overpayment recovery, measuring behavior change and completing necessary reporting for FWA recoupments and savings.

Key Responsibilities

• Identify and conduct investigations into known or suspected FWA with high autonomy
• Develop documentation to substantiate findings, including formal reports, graphs, audit logs, and other supporting documentation.
• Perform root cause analysis to inform future algorithmic identification of similar claims or cases and associated savings (i.e., help move identified case types from "pay-and-chase" to preventive edits and pre-payment activity)
• Participate in the development and presentation of FWA-related education for assigned Customers
• Perform coding reviews for flagged claims, to support Coding team (if applicable).

Requirements

Qualifications

• Education
• Bachelor's degree in Criminal Justice or a related field, OR at least 3 years of insurance claims investigation experience or professional investigation experience with law enforcement agencies.
• Experience
• Minimum of 2 years of experience in healthcare claims analysis, auditing, payment integrity, or a related field
• Knowledge of applicable fraud statutes and regulations, and of federal guidelines on recoupments and other anti-FWA activity
• Experience handling confidential information and following policies, rules, and regulations
• Experience with commercial, Medicare, or Medicaid claims is highly preferred.
• Skills
• Strong analytical and problem-solving skills, with attention to detail and accuracy.
• Excellent communication skills, both written and verbal, for effective collaboration with internal teams and external providers.
• Proficiency in Microsoft Office, particularly Excel, and familiarity with claims processing or audit software is a plus.

Preferred Qualifications

• Certifications Certified Fraud Examiner (CFE), Accredited Healthcare Fraud Investigator (AHFI), Certified AML (Anti-Money Laundering) and Fraud Professional (CAFP), or similar desired.
• Additional Certifications: Certified Professional Coder (CPC) or similar desired.