Lead Investigator, Special Investigative Unit

JOB DESCRIPTION Job Summary Provides lead level investigative support for special investigation unit (SIU) activities. Responsible for supporting for the prevention, detection, investigation, reporting, and when appropriate, recovery of money related to health care fraud, waste, and abuse (FWA). Responsible for reviewing and analyzing information to draw conclusions on allegations of FWA and/or may determine appropriateness of care, and recognizing and adhering to national and local coding and billing guidelines in order to maintain coding accuracy and excellence.

Essential Job Duties • Ensures investigators are managing their cases effectively and in accordance with special investigative unit (SIU) policies, processes, quality standards, and procedures. • Ensures that investigators are managing their respective state reporting requirements and assignments effectively and timely. • Manages the flow of day-to-day SIU investigations. • Performs assessment that quality assurance (QA) measures are complete and signed-off. • Leverages knowledge of Medicaid/Medicare/Marketplace health coverage audit policies to ensure payment integrity program compliance. •Reviews claims data, medical records and billing data from all types of health care providers that bill Medicaid/Medicare/Marketplace to determine correct coding, documentation, potential fraud, abuse, and over utilization by providers and recipients. • Provides guidance to investigators as needed on investigative techniques, tools, and strategies. • Effectively investigates and manages complex and non-complex fraud allegations. • Develops and maintains relationships with key business units within specific product lines and geographic regions. • Provides direction, instructions and guidance to investigative team, particularly in the absence of SIU leadership, and acts as backup to SIU leadership as necessary. • Provides training to team members as needed. • Communicates clear instructions to team members, listen to team members' feedback. • Monitors team members' participation to ensure the training provided is effective, and if additional training is needed. • Creates, edits, and updates assigned reports to apprise the company on the team's progress. • Distributes SIU-related reports to appropriate personnel. • Provides training, mentoring and support to new and existing SIU team members.

Required Qualifications • At least 4 years investigative experience working in a managed care organization (MCO) or health insurance company, and 3 years experience working in health care fraud-related investigations/reviews, or equivalent combination of relevant education and experience. • Valid and unrestricted driver’s license. • Proven investigatory skills including ability to organize, analyze, and effectively determine risk with corresponding solutions, and remain objective and separate facts from opinions. • Knowledge of investigative and law enforcement procedures with emphasis on fraud investigations. • Knowledge of managed care and Medicaid, Medicare, and Marketplace programs. • Understanding of claim billing codes, medical terminology, anatomy, and health care delivery systems. • Understanding of datamining and use of data analytics to detect FWA. • Ability to research and interpret regulatory requirements. • Effective interpersonal skills and customer service focus; ability to interact with individuals at all levels. • Strong presentation skills with ability to create and deliver training, informational and other types of programs. • Strong logical, analytical, critical-thinking and problem-solving skills. • Strong sense of initiative, excellent follow-through, and 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. •