Special Investigation Unit (SIU) Investigator

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 (FWA). The SIU Investigator is responsible for reviewing and analyzing information to draw conclusions on allegations of FWA. The position may also work with other internal departments, including Compliance, Legal, Payment Integrity and Medical Officers in order to achieve and maintain appropriate anti-fraud oversight.

Key Accountabilities:

• 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 but not limited to witness interviews, background checks, medical records, data analytics to identify outlier billing behavior etc.
• Completes investigations within the mandated period of time required by either state and regulations.
• Conducts both on-site and desk top investigations.
• Coordinates with various internal customers (e.g., Provider Services, Contracting and Credentialing, Healthcare Services, Member Services, Claims) to gather documentation pertinent to investigations.
• Prepares appropriate FWA referrals to regulatory agencies and law enforcement.
• Documents appropriately all case related information in the case management system in an accurate manner, including storage of case documentation following SIU related requirements.
• Renders provider education on appropriate practices (e.g., coding) as appropriate 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.
• Complies with SIU Policies as and procedures as well as goals set by SIU leadership.

Qualifications:

• Bachelor's degree or Associate's degree in criminal justice or relevant field, or equivalent work experience plus 5 years of work experience.
• Healthcare, health plan or provider SIU experience required.
• Proven investigatory skill; ability to organize, analyze, and effectively determine risk with corresponding solutions; ability to remain objective and separate facts from opinions.
• Knowledge of Managed Care and the Medicaid and Medicare programs as well as Marketplace.
• Fundamental understanding of audits and corrective actions.
• Understanding of claim billing codes, medical terminology, anatomy, and health care delivery systems.

Preferred Licenses:

• Health Care Anti-Fraud Associate (HCAFA).
• Accredited Health Care Fraud Investigator (AHFI).
• Certified Fraud Examiner (CFE).

Skills and Abilities:

• Effective interpersonal skills and customer service focus; ability to interact with individuals at all levels.
• Excellent oral and written communication skills; presentation skills with ability to create and deliver training, informational and other types of programs.
• Advanced skills in Microsoft Office (Word, Excel, PowerPoint, Outlook), SharePoint and Intra/Internet as well as proficiency with incorporating/merging documents from various applications.
• Ability to multi-task and operate effectively across geographic and functional boundaries.
• Initiative, excellent follow-through, persistence in locating and securing needed information.
• Strong logical, analytical, critical thinking and problem-solving skills.
• Proven ability to research and interpret regulatory requirements.
• Understanding of datamining and use of data analytics to detect fraud, waste, and abuse.
• Detail-oriented, self-motivated, able to meet tight deadlines.

This position is a hub-based role which requires onsite presence. To be eligible for consideration, candidates must reside within a commuting distance to one of the following office locations: Minnetonka MN, Madison WI, Omaha NE, or St Louis MO. Onsite frequency is determined by business need as decided by leadership and may be up to 2-3 days a week.

The full salary range for this position is $61,500 - $105,400. Annual salary range placement will depend on a variety of factors including, but not limited to, education, work experience, applicable certifications and/or licensure, the position's scope and responsibility, internal pay equity and external market salary data. In addition to compensation, Medica offers a generous total rewards package that includes competitive medical, dental, vision, PTO, Holidays, paid volunteer time off, 401K contributions, caregiver services and many other benefits to support our employees.

The compensation and benefits information is provided as of the date of this posting. Medica's compensation and benefits are subject to change at any time, with or without notice, subject to applicable law.

We are an Equal Opportunity employer, where all qualified candidates receive consideration for employment indiscriminate of race, religion, ethnicity, national origin, citizenship, gender, gender identity, sexual orientation, age, veteran status, disability, genetic information, or any other protected characteristic.