SIU Investigator III

🔥 13 hours 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 healthcare fraud, waste, and abuse allegations involving medical professionals, facilities, and members • Research, gather, and analyze claims, eligibility, pharmacy, and clinical data to identify trends, patterns, aberrancies, and outliers • Develop, coordinate, and conduct strategic fact-driven investigative projects • Translate analytical findings into actionable recommendations and investigative outcomes • Manage strategic investigative plans, team workload, audits, oversight, and investigation status reporting • Analyze complex provider claim submissions using coding guidelines • Interpret state Medicaid, federal Medicare, and ACA/Exchange laws, rules, and guidelines • Conduct on-site and desk audits of medical records and claims • Manage and decide claims pended for investigative purposes • Prepare and conduct complex interviews • Execute and manage provider corrective action plans • Collaborate with operational, business, legal, regulatory, law enforcement, task force, analytics, and SIU partners • Support legal actions, negotiations, recovery efforts, settlement agreements, litigation documents, and formal corrective actions • Present investigative research and internal or external presentations • Support regulatory FWA reports to federal and state Medicare/Medicaid agencies • Maintain confidential investigative information and compliance with laws, regulations, contracts, and corporate anti-fraud plans • Assist with federal and state regulatory audits and perform other job-related duties

🎯 Requirements

• Must live in Arkansas • Bachelor’s Degree or equivalent years of relevant work experience in 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 is required • One of the following certifications is required: Accredited Healthcare Fraud Investigator (AHFI) or Certified Fraud Examiner (CFE) • Intermediate proficiency in Microsoft Office, including Outlook, Word, Excel, Access, and PowerPoint • Ability to identify gaps in logic and perform intermediate data analysis • Strong interpersonal, written, problem-solving, decision-making, research, presentation, and project management skills • Ability to work under limited supervision with moderate latitude for initiative and independent judgment • Ability to manage demanding investigative caseload • Knowledge of Medicaid, Medicare, healthcare rules, medical terminology, CPT, HCPCS, ICD codes, or medical billing preferred • Master’s Degree preferred • Certified Professional Coder (CPC) preferred • NHCAA or other fraud and abuse investigation training preferred • Occasional travel up to 10% may be required

🏖️ Benefits

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