Workforce Classification:
Hybrid
The Senior Special Investigative Unit (SIU) Auditor investigates and audits potential healthcare fraud, waste, abuse, and coding irregularities across claims, billing, documentation, and reimbursement. This role requires advanced auditing expertise, industry-specific investigative knowledge, and sound judgment to identify and address improper billing and reimbursement. You will also lead proactive audit initiatives that strengthen oversight and protect the integrity of the claims process.
What You’ll Do
Audit and Coding Review
- Conduct retrospective and prospective audits of medical claims, provider billing, coding, and clinical documentation.
- Validate CPT, HCPCS, ICD-10-CM, DRG, modifier, and revenue code accuracy and reimbursement compliance.
- Apply knowledge of medical terminology, anatomy, physiology, and disease processes when evaluating records.
Investigative Analysis and Fraud Prevention
- Analyze billing trends and data to identify suspicious activity, improper reimbursement, and emerging risk.
- Develop fraud prevention strategies and support provider education, remediation, and corrective action.
- Use sound judgment to independently investigate complex issues and recommend next steps.
Reporting, Compliance, and Case Documentation
- Prepare clear audit findings, overpayment determinations, investigative documentation, and recommendations for leadership.
- Maintain confidentiality, chain-of-custody standards, and compliance with applicable laws, regulations, and coding guidance.
Legal Support, Collaboration, and Operational Execution
- Manage multiple audits and investigations, coordinating priorities, timelines, deliverables, and stakeholder communication.
- Collaborate with internal and external partners and provide affidavits or sworn testimony when needed.
- Mentor junior auditors and lead process improvements and proactive audit initiatives.
What you’ll bring:
- Bachelor’s degree in a related field or an equivalent combination of education and relevant experience (Required)
- 5 years of healthcare coding, auditing, SIU, compliance investigation, claims analysis, appeals, provider dispute, or related experience (Required)
- Active Certified Professional Coder (CPC) and Accredited Healthcare Fraud Investigator (AHFI) credentials (Required)
- Additional certification such as CPC-P, CPMA, CCS, CFE, or CHC preferred
- Experience with SIU case management systems, SQL, Excel, and data analytics or audit tools.
- Advanced knowledge of coding methodologies, healthcare compliance requirements, and fraud, waste, and abuse indicators.
- Strong analytical, problem-solving, communication, and presentation skills.
Premera total rewards
Our comprehensive total rewards package provides support, resources, and opportunities to help employees thrive and grow. Our total rewards are more than a collection of perks, they're a reflection of our commitment to your health and well-being. We offer a broad array of rewards including physical, financial, emotional, and community benefits, including:
Medical, vision, and dental coverage with low employee premiums.
Voluntary benefit offerings, including pet insurance for paw parents.
Life and disability insurance.
Retirement programs, including a 401K employer match and, believe it or not, a pension plan that is vested after 3 years of service.
Wellness incentives with a wide range of mental well-being resources for you and your dependents, including counseling services, stress management programs, and mindfulness programs, just to name a few.
Generous paid time off to reenergize.
Looking for continuing education? We have tuition assistance for both undergraduate and graduate degrees.
Employee recognition program to celebrate anniversaries, team accomplishments, and more.
For our hybrid employees, our on-campus model provides flexibility to create your own routine with access to on-site resources, networking opportunities, and team engagement.
Commuter perks make your trip to work less impactful on the environment and your wallet.
Free convenient on-site parking.
Subsidized on-campus cafes make lunchtime connections with colleagues fun and affordable.
Participate in engaging on-site activities such as health and wellness events, coffee connects, disaster preparedness fairs and more.
Our complementary fitness & well-being center offers both in-person and virtual workouts and nutritional counseling.
Need a brain break? Challenge someone to a game of shuffleboard or ping pong while on campus.
