SIU Investigator

🕒 June 13

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Devoted Health

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 2017

⚕️ Healthcare Insurance

🧘 Wellness

Healthcare Insurance • Wellness

Devoted Health is a healthcare company that offers Medicare Advantage plans designed to provide comprehensive health coverage with added benefits like dental, eyewear, gym memberships, and prescription drugs at competitive rates. The company emphasizes member support and service, ensuring that clients can easily navigate their benefits and access needed healthcare services. Devoted Health is committed to helping customers save money and enhance their health and wellness through a complete package of benefits and support.

📋 Description

• As an SIU Investigator, you'll be responsible for the full lifecycle of complex FWA investigations, acting as a subject matter expert and collaborating with various stakeholders. • Lead Complex Investigations: Plan, organize, and execute specialized investigations into allegations of healthcare fraud, waste, and abuse. • Data-Driven Detection: Utilize advanced data mining and analysis techniques to identify aberrancies and outliers in claims, medical records, enrollment, and other healthcare transactions. • Expert Guidance: Serve as a subject matter expert for other SIU Investigators, providing specialized knowledge and guidance to elevate team capabilities. • Policy & Strategy Development: Contribute to the development of robust policies and procedures related to FWA detection and investigation, as well as the annual SIU risk assessment and work plan. • Thorough Documentation & Reporting: Conduct comprehensive FWA investigations, ensuring complete and accurate case documentation and detailed investigative reports that adhere to SIU policies and standards. • External Referrals & Collaboration: Prepare comprehensive summary and detailed reports on investigative findings for referral to federal and state agencies, ensuring full compliance with regulatory requirements. • Stakeholder Engagement: Collaborate closely with internal stakeholders to share updates on FWA schemes, coordinate recommendations, and facilitate fund recovery or other necessary actions. • Provider Education: Conduct impactful provider education sessions as a direct response to investigation findings and audits. • Liaison & Point of Contact: Serve as a key point of contact for corporate and field inquiries regarding FWA, and participate in meetings with providers, business partners, regulatory agencies, and law enforcement. • Training & Development: Assist in developing and presenting engaging FWA training programs for internal and external audiences.

🎯 Requirements

• A Bachelor’s Degree in Business, Criminal Justice, Healthcare, or a related field, or equivalent relevant work experience. • Minimum of 3 years of dedicated experience in health insurance fraud investigation. • Proven experience within Medicare and/or Medicaid programs, specifically with medical claim billing, reimbursement, audit, or provider contracting. • Demonstrated experience with data analysis techniques. • Experience with the Healthcare Fraud Shield platform is a significant plus. • Ability to interpret and dissect complex data sets, identifying patterns and anomalies indicative of FWA. • Must have demonstrated experience with AI tools. • Excellent written and verbal communication skills are essential for clear report writing, compelling presentations, and effective stakeholder engagement. • A strong commitment to integrity and compliance, coupled with meticulous attention to detail in all aspects of investigations. • Proven ability to work independently, manage a diverse caseload of investigations, and thrive in a fast-paced environment, while also excelling in collaborative team settings. • Highly organized with the ability to manage multiple complex investigations simultaneously and effectively prioritize tasks. • Certified Fraud Examiner (CFE) • Certified Professional Coder (CPC).

🏖️ Benefits

• Employer sponsored health, dental and vision plan with low or no premium • Generous paid time off • $100 monthly mobile or internet stipend • Stock options for all employees • Bonus eligibility for all roles excluding Director and above • Commission eligibility for Sales roles • Parental leave program • 401K program • And more....