SIU Investigator III (Health Plan experience required) - R13201-1

Job Summary

The Special Investigations Unit (SIU) III is responsible for investigating and resolving high complexity allegations of healthcare fraud, waste and abuse (FWA) by medical professionals, facilities, and members.

About the Role

Responsible for developing, coordinating, and conducting strategic fact-driven investigative projects including business process review, execution of investigative activities, and development of investigation outcome recommendations.

Essential Functions

• Manage the development, production, and validation of reports generated from detailed claims, eligibility, pharmacy, and clinical data and translate analytical findings into actionable items.
• Ensure quality outcomes for investigative team through auditing and oversight.
• Prioritize, track, and report status of investigations.
• Report identified corporate financial impact issues.
• Research, comprehend and interpret various state specific Medicaid, federal Medicare, and ACA/Exchange laws, rules and guidelines.
• Identify, research and comprehend medical standards, healthcare authoritative sources and apply knowledge to investigative approach.
• Collaborate with data analytics team and utilize RAT STATS on Statistically Valid Random Sampling.
• Coordinate and conduct on-site and desk audits of medical record reviews and claim audits.
• Manage and decision claims pended for investigative purposes.
• Maintain a working knowledge of all state and federal laws, rules, and billing guidelines for various provider specialty types.
• Prepare and conduct in-depth complex interviews relevant to investigative plan.
• Manage and decision claims pended for investigative purposes.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
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• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.
• Manage and maintain sensitive confidential investigative information.