SIU Investigator (Full-time, Remote)

1 hour, 19 minutes ago
Full-time
Junior
Finance and Accounting
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

Description

  • Identify and investigate known or suspected healthcare fraud, waste, and abuse cases with a high degree of autonomy.
  • Analyze claims and enrollment data to assess exposure, track case activity, and manage investigations from identification through resolution.
  • Document investigative findings through formal reports, graphs, audit logs, and other supporting materials.
  • Perform root cause analysis to inform future detection logic and preventive edits for similar claims or cases.
  • Support overpayment recovery, behavior-change measurement, and required reporting for FWA recoupments and savings.
  • Collaborate with clinical subject matter experts and internal teams on investigative work and case resolution.
  • Participate in the development and presentation of fraud, waste, and abuse education for customers.
  • Conduct 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 while following policies, rules, and regulations.
  • Experience with commercial, Medicare, or Medicaid claims is highly preferred.
  • Strong analytical and problem-solving skills with exceptional 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 certifications are desired.
  • Certified Professional Coder (CPC) or similar coding certification is desired.

Interested in this position?

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