Senior SIU Investigator – CPC Required

🔥 0 minutes ago

🇺🇸 United States – Remote

💵 $64.3k - $102.9k / year

⏰ Full Time

🟠 Senior

👻 Ghost score 0%

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Magellan Health

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

🏥 Healthcare

⚕️ Healthcare Insurance

💰 $101M Private Equity Round - Magellan Health Services on 2004-01

Healthcare • Healthcare Insurance

Magellan Health is a healthcare organization focused on behavioral health and care-management services. The company provides clinical care managers, military and family life counselors, and behavioral health services across regional programs (e. g. , Magellan Hawai‘i, Magellan of New Mexico), and supports treatment coordination for mental health and substance abuse conditions. It also offers programs that support military families and other institutional clients, indicating work in managed behavioral health and care coordination.

📋 Description

• Manage and own fraud, waste, and abuse investigations • Develop and present investigative results • Perform analytical and process management tasks autonomously • Serve as a corporate resource on fraud, waste, and abuse issues • Recommend cost containment projects focused on fraud prevention • Prioritize, triage, and manage workloads to meet performance, regulatory, and contractual requirements • Create investigative work plans and case strategies • Analyze data and select audit samples using various methodologies • Plan and conduct desk audits, field audits, and site visits • Review provider, member, contractual, payment policy, and Medicaid/Medicare information • Research medical policies, practices, provider characteristics, and related topics • Interview patients, providers, staff, witnesses, and experts • Prepare correspondence and preserve evidence • Maintain comprehensive case files • Triage leads and identify suspicious patterns in claims and provider enrollment data • Monitor fraud cases, schemes, investigative techniques, and industry trends • Prepare investigative summaries, conclusions, recommendations, and reports • Identify, communicate, and recover losses • Present cases to internal departments, law enforcement, and regulatory agencies • Support legal proceedings, including court testimony and civil or criminal case preparation • Negotiate and administer settlement agreements • Present to customers, prospects, conference audiences, and law enforcement • Collaborate with clients on assignment status and direction • Maintain relationships with law enforcement, regulators, task forces, SIU staff, and external contacts • Train and guide SIU investigators • Recommend and implement procedures, process flows, and industry best practices • Represent clients at task force and regulatory meetings • Measure and report performance metrics • Recommend fraud, waste, and abuse exposure reduction opportunities • Develop anti-fraud policies and procedures • Perform other assigned duties

🎯 Requirements

• Minimum of 7 years of experience in fraud investigations or related behavioral/medical healthcare insurance experience in claims, clinical, auditing, compliance, provider networks, management, or project planning • Demonstrated abilities in time management and establishing priorities • Strong listening and observation skills • Impeccable work ethic, complete dependability, and proactive problem-solving ability • Proven ability to handle fraud and abuse cases discreetly, confidentially, and professionally • Demonstrated strategic and analytical thinking skills • Ability to communicate conclusions and recommendations effectively to management • Comprehensive, practical knowledge of complex and diverse fraud investigative techniques and methodologies used in program audits • Understanding of insurance terms and policy interpretation • Ability to work to tight timelines • Ability to work independently and collaborate with peers and customers • Ability to manage and prioritize caseload with limited supervision • Strong computer skills using Microsoft Excel, Access, Outlook, Word, and PowerPoint • Bachelor's degree required; a combination of education and work experience may be considered • CPC (Certified Professional Coder) required by job title • Preferred certifications include AHFI, CFE, CPC, LSSBB, and RN state and/or compact state licensure

🏖️ Benefits

• Short-term incentives may be available • Comprehensive benefits package • Health benefits • Life benefits • Voluntary benefits • Physical, mental, emotional and financial wellbeing perks • Tobacco-free workplace