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SIU Healthcare Investigator (Full-time, Remote)

3 hours, 6 minutes ago
United States
Full-time
Junior
Compliance Manager
Operations
Apply Now
IntegrityM

IntegrityM

Integrity Management Services Offers a large variety of data integrity solutions including audits, fraud investigations, medical reviews, and more. Certified #WOSB providing expertise in #analytics, #audits #investigations #compliance #medicalreview #s...

Professional Services
51-250
Founded 2009
View All Jobs 4

Description

  • Identify and investigate known or suspected fraud, waste, and abuse in healthcare claims with a high degree of autonomy.
  • Analyze claims and enrollment data to assess exposure, detect aberrant behavior, and manage investigative caseloads from identification through resolution.
  • Prepare supporting documentation for investigations, including formal reports, graphs, audit logs, and other evidence.
  • Perform root cause analysis to support future identification of similar claims and help move cases toward preventive edits and pre-payment controls.
  • Support overpayment recovery, measure behavior change, and complete required reporting for FWA recoupments and savings.
  • Collaborate with clinical subject matter experts and internal teams on case analysis and resolution.
  • Participate in the development and presentation of fraud, waste, and abuse education for assigned customers.
  • Perform coding reviews for flagged claims to support the coding team when applicable.

Requirements

  • 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.
  • Minimum of 2 years of experience in healthcare claims analysis, auditing, payment integrity, or a related field.
  • Knowledge of applicable fraud statutes and regulations, as well as 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.
  • Strong analytical and problem-solving skills with excellent attention to detail and accuracy.
  • Excellent written and verbal communication skills for collaboration with internal teams and external providers.
  • Proficiency in Microsoft Office, especially Excel, and familiarity with claims processing or audit software is a plus.
  • Certified Fraud Examiner (CFE), Accredited Healthcare Fraud Investigator (AHFI), Certified AML and Fraud Professional (CAFP), or similar certification is desired.
  • Certified Professional Coder (CPC) or similar certification is desired.

Interested in this position?

Apply directly on the company website

Apply Now

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