SIU Auditor

Remote within the United States with Delaware residency preferred. For roles that are 100% remote or hybrid, you must have access to a reliable high-speed internet connection to support daily job responsibilities. A minimum bandwidth of 50 Mbps download and 5 Mbps upload is required.

Responsibilities

• Ensures compliance with all requirements related to Special Investigation Units and fraud, waste and abuse investigations.
• Conducts comprehensive interviews with providers, members and witnesses to obtain information which would be considered admissible under generally accepted criminal and civil rules of evidence.
• Proactively performs research using the Internet, data analysis tools, etc., to analyze aberrant claims billing and practice patterns.
• Conducts proactive data mining and analyzes data as part of the investigative process using available fraud detection software and corporate resources.
• Prepares and submits investigative reports covering all phases of the investigation.
• Interprets and conveys highly technical information to others.
• Establishes and maintains liaison with public officials, law enforcement and others to obtain assistance in conducting investigations.
• Knowledge of available resources (internal and external) to assist in investigations.

Requirements

• Bachelor’s Degree preferred or equivalent work experience in healthcare-related fields.
• 1+ years of Auditing experience or related experience in healthcare.
• Medicaid experience preferred.
• SIU and/or State Medicaid regulatory compliance work experience a plus.
• Knowledge and proficiency in claims adjudication standards & procedures preferred.
• Experience with Medicaid, Medicare, and/or pharmacy benefit reimbursement.
• Solid knowledge of Medicaid, Medicare, and pharmacy benefit laws and requirements; federal, state, civil and criminal statutes.
• Experience with decision support tools used for data analysis.
• Advanced knowledge and experience working on various approaches to fraud, waste and abuse.
• Working knowledge of Microsoft applications, especially Excel required.
• Analytical skills and ability to make deductions; logical and sequential thinker.
• Experience with LTSS preferred.
• Valid driver’s license required.
• Strong verbal and written communication skills.

Benefits

• Flexible work solutions including remote options, hybrid work schedules.
• Competitive pay.
• Paid time off including holidays and volunteer events.
• Health insurance coverage for you and your dependents on Day 1.
• 401(k).
• Tuition reimbursement and more.