Job Description

Job Summary

The Special Investigation Unit (SIU) Investigator is responsible for supporting the prevention, detection, investigation, reporting, and when appropriate, recovery of money related to health care fraud, waste, and abuse. Duties include performing accurate and reliable medical review audits that may also include coding and billing reviews. The SIU Investigator is responsible for reviewing and analyzing information to draw conclusions on allegations of FWA and/or may determine appropriateness of care. The SIU Investigator is also responsible for recognizing and adhering to national and local coding and billing guidelines in order to maintain coding accuracy and excellence. The position entails producing audit reports for internal and external review and may involve working with other internal departments, including Compliance, Corporate Legal Counsel, and Medical Officers to maintain appropriate anti-fraud oversight.

Job Duties

• Responsible for developing leads presented to the SIU to assess and determine whether potential fraud, waste, or abuse is corroborated by evidence.
• Conducts both preliminary assessments of FWA allegations and end-to-end full investigations, including witness interviews, background checks, data analytics to identify outlier billing behavior, contract and program regulation research, provider and member education, findings identification and communications development, and recommendations and preparation of overpayment identifications and closure of investigative cases.
• Completes investigations within the mandated period of time required by either state and/or federal contracts and/or regulations.
• Conducts both on-site and desk-top investigations.
• Conducts low to medium, and extensive investigations, including reviews of medical records and data analysis, and makes determinations as to whether the investigation and/or audit identified potential fraud, waste, or abuse.
• Coordinates with various internal customers (e.g., Provider Services, Contracting and Credentialing, Healthcare Services, Member Services, Claims) to gather documentation pertinent to investigations.
• Detects potential health care fraud, waste, and abuse through the identification of aberrant coding and/or billing patterns through utilization review.
• Prepares appropriate FWA referrals to regulatory agencies and law enforcement.
• Documents appropriately all case-related information in the case management system, including storage of case documentation following SIU related requirements.
• Prepares detailed preliminary and extensive investigation referrals to state and/or federal regulatory and/or law enforcement agencies when potential fraud, waste, or abuse is identified as required by regulatory and/or contract requirements.
• Renders provider education on appropriate practices (e.g., coding) based on national or local guidelines, contractual, and/or regulatory requirements.
• Interacts with regulatory and/or law enforcement agencies regarding case investigations.
• Prepares audit results letters to providers when overpayments are identified.
• Works may be remote, in office, and on-site travel within the state of New York as needed.
• Ensures compliance with applicable contractual requirements, and federal and state regulations.
• Complies with SIU Policies and procedures as well as goals set by SIU leadership.
• Supports SIU in arbitrations, legal procedures, and settlements.
• Actively participates in MFCU meetings and roundtables on FWA case development and referral.

Job Qualifications

• Required Education: Bachelor's degree or Associate’s Degree in criminal justice or equivalent combination of education and experience.
• Required Experience/Knowledge, Skills & Abilities: 1-3 years of experience; proven investigatory skill; ability to organize, analyze, and effectively determine risk with corresponding solutions; knowledge of investigative and law enforcement procedures; understanding of claim billing codes, medical terminology, anatomy, and health care delivery systems; effective interpersonal skills; excellent oral and written communication skills; advanced skills in Microsoft Office and data analytics.
• Required License, Certification, Association: Valid driver’s license required.
• Preferred Experience: At least 5 years of experience in FWA or related work.
• Preferred License, Certification, Association: HCAFA, AHFI, CFE certification preferred.

Compensation Information

• Pay Range: $21.82 - $51.06 / Hourly
• Actual compensation may vary from posting based on geographic location, work experience, education, and/or skill level.

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