SIU Investigator III

🔥 4 minutes ago

🇺🇸 United States – Remote

💵 $65k - $104k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

👻 Ghost score 0%

What it means: how likely this posting is sitting open without active hiring.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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CareSource

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 30+ years

🏥 Healthcare

🛡️ Insurance

⚕️ Healthcare Insurance

Healthcare • Insurance • Healthcare Insurance

CareSource is a health services company focused on providing affordable health insurance and healthcare solutions. It offers a wide range of plans including Medicaid, Marketplace, and Medicare Advantage, targeting low-income adults, families, children, pregnant women, elderly adults, and people with disabilities. Additionally, CareSource provides members with resources for COVID-19 support, dental, vision, and hearing benefits, as well as pharmacy services. The company emphasizes easy access to healthcare management through online platforms and a mobile app.

📋 Description

• Investigate and resolve high-complexity allegations of healthcare fraud, waste, and abuse involving medical professionals, facilities, and members • Research, gather, and analyze data to identify trends, patterns, aberrancies, and outliers in provider billing behavior • Serve as a subject matter expert for other investigators • Develop, coordinate, and conduct strategic fact-driven investigative projects • Manage development, production, and validation of reports using claims, eligibility, pharmacy, and clinical data • Translate analytical findings into actionable items and drive investigative outcomes • Audit and oversee investigative team quality outcomes • Prioritize, track, and report investigation status • Report identified corporate financial impact issues • Analyze complex provider claim submissions using coding guidelines • Interpret state Medicaid, federal Medicare, and ACA/Exchange laws, rules, and guidelines • Apply medical standards and healthcare authoritative sources to investigative approaches • Collaborate with data analytics teams and use RAT-STATS for statistically valid random sampling • Conduct on-site and desk audits of medical records and claims • Manage and decide claims pended for investigative purposes • Conduct in-depth complex interviews • Execute and manage provider formal corrective action plans • Meet with operational departments, business partners, regulatory partners, and Legal General Counsel to develop cases and pursue legal actions, corrective actions, negotiations, recoveries, settlements, and litigation documents • Present, support, and defend investigative research for formal corrective actions • Maintain relationships with law enforcement agencies, task force members, SIU staff, and external fraud-investigation contacts • Serve as subject matter expert in the designated market and apply external intelligence to case analysis and development • Develop and present internal and external formal presentations • Attend fraud, waste, and abuse training and conferences • Support regulatory FWA reports to federal and state Medicare/Medicaid agencies • Manage sensitive confidential investigative information • Maintain compliance with laws, regulations, contracts, Corporate Compliance Plan, and Anti-Fraud Plan • Assist with federal and state regulatory audits • Perform other job-related instructions as requested

🎯 Requirements

• Must live in Arkansas • Bachelor's Degree or equivalent years of relevant work experience in a health-related field, law enforcement, or insurance required • Minimum of five (5) years of experience in healthcare fraud investigations, medical coding, pharmacy, medical research, auditing, data analytics, or related field required • One of the following certifications required: Accredited Healthcare Fraud Investigator (AHFI) or Certified Fraud Examiner (CFE) • Intermediate proficiency in Microsoft Office, including Outlook, Word, Excel, Access, and PowerPoint • Effective listening and critical thinking skills; ability to identify gaps in logic • Strong interpersonal skills, professionalism, integrity, and ethics • Excellent problem-solving and decision-making skills with attention to detail • Background in research and drawing conclusions • Ability to perform intermediate data analysis and articulate findings • Ability to work under limited supervision with moderate latitude for initiative and independent judgment • Ability to manage a demanding investigative caseload • Ability to develop, prioritize, and accomplish goals • Strong writing skills and ability to compose detailed investigative reports and professional correspondence • Presentation experience beneficial • Knowledge of Medicaid, Medicare, and healthcare rules preferred • Background in medical terminology, CPT, HCPCS, ICD codes, or medical billing preferred • Complex project management skills preferred • Leadership qualities • Certified Professional Coder (CPC) preferred • NHCAA or other fraud and abuse investigation training preferred

🏖️ Benefits

• Bonus tied to company and individual performance may be available • Comprehensive total rewards package • Occasional travel to meetings, training, and conferences