Special Investigations Investigator, Consultant

Your Role

The Special Investigations Unit (SIU) team is responsible for investigations of suspected fraud, waste or abuse involving health care providers, facilities, subscribers, brokers and/or employer groups. Serve as a liaison with law enforcement and regulatory agencies. Coordinate with internal business units and other health plans. The Special Investigations Investigator Consultant will report to the SIU Manager. In this role you will represent a high level of professionalism both internally and externally. Conduct investigations in accordance with company policies and procedures and in compliance with all applicable laws and regulations.

Your Knowledge and Experience

• Requires a college degree or equivalent experience
• Requires a minimum of 7 years of prior relevant experience, inclusive of experience with health insurance claims, medical coding experience, and investigative experience
• Requires deep knowledge of investigations typically obtained through advanced education combined with experience
• Typically, viewed as a specialist within discipline. May have broad knowledge of project management
• Requires FACETS experience
• Requires extensive knowledge of health insurance reimbursement methodologies, including ICD-10 CM, CPT and HCPCS coding
• Requires the ability to travel as required, including occasional overnight stay
• Requires proficiency in Microsoft Office, experience with Tableau, and Excel spreadsheets with pivot tables.
• Requires the ability to read and understand medical documentation
• Requires excellent analytical and critical thinking skills
• Requires CPC or equivalent medical coding certification or the ability to obtain within 2 years of employment
• Requires knowledge and experience of Medicare, Medi-Cal, and other government programs.
• Requires excellent written and verbal communication skills for correspondence and negotiations with attorneys and providers