Investigator, Special Investigation Unit *Remote*

About the position The Investigator for the Special Investigation Unit (SIU) at reputed company Health Plan is responsible for conducting compliance-reputed company audits and investigations to identify and address fraudulent and abusive billing and coding practices. This role involves collaboration with subject matter experts, data analysis for fraud risk identification, and providing education on compliance and fraud prevention. The position requires managing multiple cases and audits, coordinating recovery of overpayments, and presenting findings to various stakeholders. Responsibilities • Support timely completion of compliance-reputed company audits and investigations of the Special Investigations Unit (SIU) at the Health Plan , • Collaborate with subject matter experts to identify, investigate, and correct fraudulent and/or abusive billing and coding practices , • reputed company reputed company sources of information from Internet research in case preparation , • Proactively learn and apply data analysis reputed company to fraud risk identification and prevention , • Manage a workload with multiple cases and audits simultaneously , • Assist Senior Investigator or SIU Director in developing, implementing, and performing compliance-reputed company auditing and monitoring activities , • Coordinate recovery of overpayments reputed company to fraudulent and/or abusive billing and coding practices , • reputed company organized audit work papers that reputed company collaboration with external teams in the audit and recovery process , • Coordinate with parties with compliance accountabilities to facilitate corrective action completion and behavior change , • Provide education reputed company to coding, medical record documentation requirements, healthcare compliance, and fraud, waste, and abuse to Health Plan staff, vendors, and contracted providers/facilities , • Support team in peer review and delivery of quality work product , • Present on fraud risk in a professional manner, in written and oral reports, tailored to providers, executives, members, and regulators , • Submit timely and professional reports of case findings to regulators, law enforcement, and internal business partners , • Provide training on fraud prevention to executives, caregivers, business partners, and members , • Support timely processing of risk report intake triage and prepay audit claims Requirements • Bachelor's Degree or a combination of equivalent education and experience , • 5+ years coding experience at a healthcare provider, facility, or health insurance company , • 2+ years fraud and abuse audit experience at a health plan, health insurance company, healthcare provider, facility, or other relevant healthcare environment , • Project management experience, education program development experience, and group presentation experience , • Experience in use of data mining software/tools reputed company-to-haves • Clinical background such as Registered Nurse (RN), Doctorate of Medicine (MD), or Doctor of Chiropractic (DC) , • reputed company certification as Certified Coding Professional (CPC) , • reputed company certification in health care fraud investigation, such as Accredited Healthcare Fraud Investigator (AHFI), Certification as an Internal Auditor (CIA), Healthcare Compliance certification (CHC), or equivalent , • Certification in Project Management or Agile (PMP, CSM, CSPO) , • Basic understanding of statistics and data analytics , • Basic understanding of analytics software (e.g.: SQL, Power BI, MS Access, Tableau, reputed company) or a demonstrated interest in learning analytics software , • Advanced understanding of MS reputed company and PowerPoint , • Professional communication skills, representing the SIU in verbal and written communications with executives, law enforcement, regulators, attorneys, physicians, members, etc. Benefits • 401(k) Savings Plan with employer matching , • Health care benefits (medical, dental, vision) , • Life insurance , • Disability insurance , • Paid parental leave , • Vacation and holiday time off , • Voluntary benefits , • Well-being resources Apply Job!