Job SummaryThe Senior Investigator is an essential team member of the SIU (Special Investigations Unit), responsible for leading complex provider investigations related to fraud, waste, and abuse, and developing action plans to address the investigative findings and prevent future loss. The Senior Investigator works closely with other members of the SIU to set investigative priorities, develop effective investigative strategies and techniques, and recommend measures to address new and evolving schemes. The Senior Investigator also serves as a resource to fellow SIU members and other Plan departments in the investigator's areas of investigative and clinical expertise.
Job Description Key Responsibilities/Duties - what you will be doing (top five):
- Lead complex investigations, involving internal and external research, detailed data analyses, review of medical records, and interviews of members, providers, and other third parties.
- Apply laws, regulations, plan policies and guidelines, contract provisions, coding rules, coverage rules, and industry standards to information gathered during the investigation.
- Prepare reports of investigative findings and reporting investigative findings to providers.
- Work with SIU management to educate providers, recover overpayments, take action to prevent future loss, and monitor provider activity post-investigation
- Identify root causes of fraud, waste and abuse and recommend internal and external corrective actions to address these root causes.
- Recommend investigative priorities, strategies, and techniques.
- Work with the analytics and intake team to develop and refine data mining to address new and evolving schemes.
- Sharie expertise and promoting investigative best practices among SIU management and staff. Educating and collaborating with various business units to raise awareness of potential FWA (Fraud Waste and Abuse) concerns.
- Perform out-of-the-box thinking, collaborate with others, and make a difference every day!
- Other duties as assigned by the Director.
Qualifications - what you need to perform the job
Certification and Licensure:
- Certified Professional Coder ("CPC")
- Certified Fraud Examiner ("CFE") designation a plus.
Education
- Required (minimum): Bachelor's degree, preferably in a clinical or scientific field, business, computer science, or criminal justice.
- Preferred:
Experience
- Required (minimum): 5-7 years' related experience in health insurance fraud investigations.
- Preferred: 3 years' related experience in audits/investigations.
Skill Requirements
- Ability to produce clear, concise, and well-organized documents.
- Resilient, collaborative, flexible, innovative.
Working Conditions and Additional Requirements (include special requirements, e.g., lifting, travel):
- Must be able to work under normal office conditions and work from home as required.
- May be required to attend meetings at other company locations or other external meetings.
- Work may require simultaneous use of a telephone/headset and PC/keyboard and sitting for extended durations.
- May be required to work additional hours beyond standard work schedule.
DISCLAIMER
The above statements are intended to describe the general nature and level of work being performed by employees assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of employees assigned to this position. Management retains the discretion to add to or change the duties of the position at any time.
Salary Range$92,414.18 -$138,621.26
Compensation & Total Rewards OverviewThe annual base salary range provided for this position represents a range of salaries for this role and similar roles across the organization. The actual salary for this position will be determined by several factors, including the scope and complexity of the role; the skills, education, training, credentials, and experience of the candidate; as well as internal equity. As part of our comprehensive total rewards program, colleagues are also eligible for variable pay. Eligibility for any bonus, commission, benefits, or any other form of compensation and benefits remains in the Company's sole discretion and may be modified at the Company's sole discretion, consistent with the law.
Point32Health offers their Colleagues a competitive and comprehensive total rewards package which currently includes:
- Medical, dental and vision coverage
- Retirement plans
- Paid time off
- Employer-paid life and disability insurance with additional buy-up coverage options
- Tuition program
- Well-being benefits
- Full suite of benefits to support career development, individual & family health, and financial health
For more details on our total rewards programs, visit https://www.point32health.org/careers/benefits/
