Overview

The SIU Analyst II conducts end to end fraud, waste and abuse investigations on referred cases that have been triaged for investigative handling. This role is responsible for developing the investigative plan, gathering and analyzing data, documenting findings and producing clear, defensible case files and reports to support recoveries, administrative actions, referrals and other program outcomes. The SIU Analyst II works independently on moderately complex cases, collaborates with clinical and analytics partners as needed and ensures investigative activities meet regulatory requirements, policy standards and evidentiary expectations. This role also supports team success by contributing investigative expertise, mentoring SIU Analyst I staff on quality fundamentals and escalating risk, trends and barriers to case progression.

Responsibilities/ Requirements

Responsibilities:

• Evaluate and develop leads, complaints, and/or investigations to determine if further investigation is warranted
• Execute assigned investigations from start to closure (post-triage), including strategy, documentation and recommendations
• Conduct interviews and outreach as required
• Build defensible case narrative and prepare findings report with clear overpayment/impact logic (when applicable)
• Utilize data analysis techniques to detect aberrancies in our health plan clients92 Commercial, Medicare, Medicaid, ACA/Exchange, FEHB, and Tricare claims data, and proactively seeks out and develops leads/investigations received from a variety of sources
• Review information contained in standard claims processing system files (e.g., claims history, provider files) to determine provider billing patterns and to detect potential fraudulent or abusive billing practices or vulnerabilities in health plan, Medicare and/or Medicaid payment policies and recommend appropriate action
• Make potential fraud determinations by utilizing a variety of sources such as internal guidelines, Medicare and Medicaid provider manuals, Medicare and Medicaid regulations, health plan client resources, guidelines, and policies
• Compile and maintain documentation and information related to investigations, cases, and/or leads
• Participate in onsite audits in conjunction with investigation development
• Develop and prepare potential Fraud Alerts and program vulnerabilities for submission to health plan clients, law enforcement, and other applicable stakeholders
• Prepare and submit external correspondence and reports, including, but not limited to, overpayment letters, fraud case referrals, rebuttals, findings reports, and administrative action recommendations
• Prepare and submit correspondence to providers for medical record requests or suspension overpayment determinations
• Serve as mentor/trainer to new CoventBridge Healthcare SIU staff

Requirements:

• Research and organization skills
• Ability to establish and/or evaluate prioritization criteria
• Time management skills and ability to meet deadlines
• Verbal and written communication skills
• Ability to work independently with minimal supervision
• Ability to multi-task in a fast-paced environment

Educational/Experience Qualifications:

• College or technical degree programs related to the position (e.g., Criminal Justice, Statistics, Data Analysis, etc.)
• Candidates with Accredited Health Care Fraud Investigator (AHFI) and Certified Fraud Examiner (CFE) Certifications will be given priority consideration
• At least 1 year of experience in SIU, Program Integrity investigation/detection or a related field that demonstrates expertise in reviewing, analyzing/developing information, and making appropriate decisions

Benefits

Benefits:

• Medical, Dental, Vision plans
• Life, LTD and STD paid by the employer
• 401(k) with company match up to 4%
• Paid Time Off and company paid holidays
• Tuition assistance after 1 year of service

The salary range for this role is $74,000 to $87,000 annually. This is the lowest to highest salary we in good faith believe we would pay for this role at the time of this posting. We may ultimately pay more or less than the posted range, and the range may be modified in the future. An employee92s pay position within the salary range will be based on several factors including, but not limited to, relevant education, qualifications, certifications, experience, skills, geographic location, performance, and business or organizational needs.

Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.