Investigator, Special Investigation Unit (Remote) - Bryant Staffing Solutions

Job Summary:
SIU Investigator conducts investigations into potential billing and claims fraud for the health plan. Responsibilities include working with experts, using data analysis, coordinating with stakeholders, and recovering overpayments. The role also involves educating staff on fraud prevention, supporting audits, and preparing reports for regulators and internal partners. This position requires strong analytical skills, attention to detail, and the ability to manage multiple cases at once.

Responsibilities:

• Support timely completion of compliance audits and investigations for the SIU at the Health Plan.
• Collaborate with subject matter experts to investigate and correct fraudulent or abusive billing and coding practices.
• Utilize credible internet sources for case preparation.
• Learn and apply data analysis for fraud risk identification and prevention.
• Manage multiple cases and audits simultaneously.
• Assist Senior Investigator or SIU Director with compliance-related auditing and monitoring activities.
• Coordinate recovery of overpayments from fraudulent or abusive billing practices and maintain organized audit work papers.
• Facilitate corrective actions and behavior change with compliance accountabilities.
• Provide education on coding, medical record documentation, healthcare compliance, and fraud to staff, vendors, and providers.
• Support team in peer reviews and ensure quality work product.
  Present fraud risk findings professionally in written and oral reports to various stakeholders.
• Submit timely and professional case findings to regulators, law enforcement, and internal partners.
• Train executives, caregivers, business partners, and members on fraud prevention.
• Support timely processing of risk report intake, prepay audit claims, and other compliance requirements.

Required Qualifications:

• Bachelor's Degree -OR- a combination of equivalent education and experience
• At least 5 years coding experience at a healthcare provider, facility or health insurance company
• At least 2 years fraud and abuse audit experience at a health plan, health insurance company, healthcare provider, facility or other relevant healthcare environment
• Project management experience, education program development experience and group presentation experience
• Experience in use of data mining software/tools

• Clinical background such as Registered Nurse (RN), Doctorate of Medicine (MD), or Doctor of Chiropractic (DC) 
• Current certification as Certified Coding Professional (CPC)
• Current certification in health care fraud investigation, such as Accredited Healthcare Fraud Investigator (AHFI), Certification as an Internal Auditor (CIA), Healthcare Compliance certification (CHC), or equivalent
• Certification in Project Management or Agile (PMP, CSM, CSPO)
• Basic understanding of statistics and data analytics
• Basic understanding of analytics software (e.g.: SQL, Power BI, MS Access, Tableau, Alteryx) or a demonstrated interest in learning analytics software
• Advanced understanding of MS Excel and PowerPoint
• Professional communication skills, representing the SIU in verbal and written communications with executives, law enforcement, regulators, attorneys, physicians, members, etc.

• Medical, dental and vision insurance
• Basic and supplemental life insurances and AD&D
• Disability benefits
• Flexible spending accounts
• Paid time away (vacations, holidays, illness)
• Voluntary benefits, such as:
• • Pet insurance
  • Legal insurance
  • Home and auto insurance
  • Identity and credit protection
  • Accident and critical illness insurance
  • Voluntary short-term disability
  • Commuter benefits