Job Details

Special Investigation Unit Investigator

The Special Investigation Unit (SIU) Investigator is responsible for supporting the prevention, detection, investigation, reporting, and when appropriate, recovery of money related to health care fraud, waste, and abuse. Duties include performing accurate and reliable medical review audits that may also include coding and billing reviews. The SIU Investigator is responsible for reviewing and analyzing information to draw conclusions on allegations of FWA and/or may determine appropriateness of care. The SIU Investigator is also responsible for recognizing and adhering to national and local coding and billing guidelines in order to maintain coding accuracy and excellence. The position also entails producing audit reports for internal and external review. The position may also work with other internal departments, including Compliance, Corporate Legal Counsel, and Medical Officers in order to achieve and maintain appropriate anti-fraud oversight.

Job Duties:

• Responsible for developing leads presented to the SIU to assess and determine whether potential fraud, waste, or abuse is corroborated by evidence.
• Conducts both preliminary assessments of FWA allegations, and end to end full investigations, including but not limited to witness interviews, background checks, data analytics to identify outlier billing behavior, contract and program regulation research, provider and member education, findings identification and communications development, and recommendations and preparation of overpayment identifications and closure of investigative cases.
• Completes investigations within the mandated period of time required by either state and/or federal contracts and/or regulations.
• Conducts both on-site and desk top investigations.
• Conducts low to medium, and extensive investigations, including reviews of medical records and data analysis, and makes determinations as to whether the investigation and/or audit identified potential fraud, waste, or abuse.
• Coordinates with various internal customers (e.g., Provider Services, Contracting and Credentialing, Healthcare Services, Member Services, Claims) to gather documentation pertinent to investigations.
• Detects potential health care fraud, waste, and abuse through the identification of aberrant coding and/or billing patterns through utilization review.
• Prepares appropriate FWA referrals to regulatory agencies and law enforcement.
• Documents appropriately all case related information in the case management system in an accurate manner, including storage of case documentation following SIU related requirements.
• Prepares detailed preliminary and extensive investigation referrals to state and/or federal regulatory and/or law enforcement agencies when potential fraud, waste, or abuse is identified as required by regulatory and/or contract requirements.
• Renders provider education on appropriate practices (e.g., coding) as appropriate based on national or local guidelines, contractual, and/or regulatory requirements.
• Interacts with regulatory and/or law enforcement agencies regarding case investigations.
• Prepares audit results letters to providers when overpayments are identified.
• Works may be remote, in office, and on-site travel within the state of New York as needed.
• Ensures compliance with applicable contractual requirements, and federal and state regulations.
• Complies with SIU Policies as and procedures as well as goals set by SIU leadership.
• Supports SIU in arbitrations, legal procedures, and settlements.
• Actively participates in MFCU meetings and roundtables on FWA case development and referral.

Job Qualifications:

Required Education:

• Bachelors degree or Associate's Degree, in criminal justice or equivalent combination of education and experience

Required Experience/Knowledge, Skills & Abilities:

• 1-3 years of experience, unless otherwise required by state contract
• Proven investigatory skill; ability to organize, analyze, and effectively determine risk with corresponding solutions; ability to remain objective and separate facts from opinions.
• Knowledge of investigative and law enforcement procedures with emphasis on fraud investigations.
• Knowledge of Managed Care and the Medicaid and Medicare programs as well as Marketplace.
• Understanding of claim billing codes, medical terminology, anatomy, and health care delivery systems.
• Understanding of datamining and use of data analytics to detect fraud, waste, and abuse.
• Proven ability to research and interpret regulatory requirements.
• Effective interpersonal skills and customer service focus; ability to interact with individuals at all levels.
• Excellent oral and written communication skills; presentation skills with ability to create and deliver training, informational and other types of programs.
• Advanced skills in Microsoft Office (Word, Excel, PowerPoint, Outlook), SharePoint and Intra/Internet as well as proficiency with incorporating/merging documents from various applications.
• Strong logical, analytical, critical thinking and problem-solving skills.
• Initiative, excellent follow-through, persistence in locating and securing needed information.
• Fundamental understanding of audits and corrective actions.
• Ability to multi-task and operate effectively across geographic and functional boundaries.
• Detail-oriented, self-motivated, able to meet tight deadlines.
• Ability to develop realistic, motivating goals and objectives, track progress and adapt to changing priorities.
• Energetic and forward thinking with high ethical standards and a professional image.
• Collaborative and team-oriented

Required License, Certification, Association:

• Valid driver's license required.

Preferred Experience:

• At least 5 years of experience in FWA or related work.

Preferred License, Certification, Association:

• Health Care Anti-Fraud Associate (HCAFA).
• Accredited Health Care Fraud Investigator (AHFI).
• Certified Fraud Examiner (CFE).