Senior Investigator, Special Investigative Unit

**Job Description** **Job Summary** Provides senior level support for special investigation unit (SIU) activities. Responsible for supporting for the prevention, detection, investigation, reporting, and when appropriate, recovery of money related to health care fraud, waste, and abuse (FWA). Responsible for reviewing and analyzing information to draw conclusions on allegations of FWA and/or may determine appropriateness of care, and recognizing and adhering to national and local coding and billing guidelines in order to maintain coding accuracy and excellence. **Essential Job Duties** • Responds to allegations of potential fraud, waste and abuse (FWA); conducts the investigation of fraudulent, wasteful and abusive activities involving members and providers. • Analyzes enrollment data, medical claims data, contract terms, financial records, provider and member claims history, and other documentation to determine FWA and identify potential patterns. • Applies regulatory and contractual requirements as well as internal policies and procedures to the case investigation process. • Perform data analysis, research and review of claims data to identify trends, patterns, outliers and emerging issues in health care FWA with fraud technology. • Conducts investigations and interviews to gather additional evidence. • Researches and investigates member identity theft cases through internal Alertline. • Communicates with members and providers routinely regarding issues including investigative findings, recoveries, and educational feedback where appropriate. • Compiles, reports and presents case information to the appropriate Medicaid fraud control unit or other regulatory agency. • Maintains the integrity of documentation for FWA cases; updates the case management system to ensure documentation of all calls, evidence, referrals, inquiries and case events are accurate for record keeping purposes and for “discovery” in court related cases. • Establishes and maintains strong relationships with external agencies including the Department of Health and Human Services (DHHS), Office of Inspector General (OIG), Drug Enforcement Administration (DEA), state professional licensing boards, US Attorney's office and state/local law enforcement agencies. • Prepares data requests from external law enforcement agencies as required. • Travels to conduct provider onsite audits and investigations. • Writes clear and concise reports, presents findings to providers and participates in negotiated resolution of issues at the direction of management. Tracks and reports any overpayment as a result of an investigation. • Uses findings to determine where there is a need for a change in policy and course of appropriate action based on line of business, severity of issue, regulatory compliance requirements and plan exposure. • Vets new concepts for building additional investigation opportunities/clearer review guidelines for cases. • Assist SIU leadership in case review and resolution. • Provides guidance to investigators as needed on investigative techniques, tools, or strategy. • Effectively investigates and manages complex and non-complex fraud allegations. • Develops and maintains relationships with key business units within specific product line and geographic region. • Provides direction, instructions and guidance to Investigative team, particularly in the absence of SIU leadership. • Creates, edits, and updates assigned reports to apprise the company on the team's progress. • Provides training and support to new and existing SIU team members. **Required Qualifications** **• At least 3 years investigative experience in the health care industry, or equivalent combination of relevant education and experience.** **• Valid and unrestricted driver’s license.** **• Proven investigatory skills including ability to organize, analyze, and effectively determine risk with corresponding solutions, and remain objective and separate facts from opinions.** **• Knowledge of inves…