SIU Investigator

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🔥 2 minutes ago

🦞 Maine – Remote

🦞 Maine – Remote

💵 $75.6k - $93.4k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

👻 Ghost score 0%

What it means: the chance that no one is really hiring for this job.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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Martin's Point Health Care

WebsiteLinkedInAll Job Openings

501 - 1000 employees

🛡️ Insurance

📦 Logistics

💼 Consulting

Insurance • Logistics • Consulting

Martin's Point Health Care is a healthcare organization committed to serving its local communities through high-quality primary and specialty care services. The organization places a strong emphasis on creating a positive workplace culture, recognizing employee contributions, and fostering workforce diversity. Martin's Point Health Care offers a range of career opportunities across various departments, from healthcare providers to corporate roles, and supports employee growth through competitive compensation, development programs, and generous perks. Additionally, the company is recognized for its community impact efforts, raising significant funds for community organizations and encouraging employee volunteerism.

📋 Description

• Investigate suspected fraud, waste and abuse from start to finish • Develop case plans defining allegations, scope, and estimated financial exposure • Analyze claims data to identify unusual billing patterns, estimate overpayment exposure, and support sampling and extrapolation • Review medical records and supporting documentation against CMS and TRICARE requirements, payment policies, coding guidelines, and coverage determinations • Coordinate clinical and coding review with internal departments • Conduct member and provider outreach, including investigative interviews • Maintain thorough, well-documented case files • Draft findings letters and overpayment determinations • Recommend corrective actions including provider education, prepayment review, recoupment, and network action • Prepare referrals to CMS Investigations MEDIC, the Defense Health Agency Program Integrity Office, HHS-OIG, and law enforcement • Respond to oversight entities’ requests for information • Maintain accurate case management records and contribute to SIU reporting on recoveries, cost avoidance, and referrals • Track emerging fraud schemes and help develop new analytics and edits • Support FWA compliance obligations and contribute to FWA training content • Help shape investigative standards, procedures, and cross-functional workflows for the newly established SIU • Report to the Director, Special Investigations Unit

🎯 Requirements

• Bachelor’s degree in criminal justice, health care administration, accounting, or other related field, or an equivalent combination of education and experience • Five or more years in health care fraud investigation, SIU, payment integrity, program integrity, or law enforcement health care fraud work required • Medicare Advantage experience required • TRICARE or other government program experience preferred • Working knowledge of Medicare Advantage program integrity requirements, the False Claims Act, the Anti-Kickback Statute, the Stark Law, and overpayment reporting obligations • Strong command of CMS-1500 and UB-04 claim formats and coding conventions • Investigative writing that can withstand legal and regulatory scrutiny • Skilled interviewer with sound judgment, discretion, and rigorous handling of protected health information (PHI) • Advanced Excel skills, SQL, PowerBI, or similar tools strongly preferred • Able to work independently and contribute in a start-up environment where procedures are still being built • At least one of the following certifications preferred: AHFI, CFE, CPC, CCS, or CPMA • This position is not eligible for immigration sponsorship

🏖️ Benefits

• medical insurance • dental insurance • vision insurance • retirement savings with employer contributions • paid time off • volunteer time off • pie day • other employee benefits

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