Senior SIU Investigator – CPC Required

🕒 October 8

🇺🇸 United States – Remote

💵 $64.3k - $102.9k / year

⏰ Full Time

🟠 Senior

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

👻 Ghost score 3%

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.

Apply Now

Find Similar Remote Jobs

Magellan Health

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

💼 Consulting

🛡️ Insurance

🏥 Healthcare

💰 $101M Private Equity Round on 2004-01

Consulting • Insurance • Healthcare

Magellan Health is a leading healthcare management company that provides a range of services, including behavioral health, pharmacy management, and employee assistance programs. The company focuses on delivering high-quality care and support to individuals and families, particularly those in military and community settings. Magellan Health emphasizes personalized service and innovative solutions to improve health outcomes and enhance the overall patient experience.

📋 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

📊 Check your resume score for this job

Improve your chances of getting an interview by checking your resume score before you apply.

Upload Resume