Special Investigations Investigator, Consultant

Your Role

The Special Investigations Unit (SIU) team is responsible for preventing, detecting, investigating, and resolving health care fraud, waste, and abuse. The Special Investigations Investigator, Consultant will report to the SIU Manager. In this role you will conduct investigations in accordance with company policies and procedures and in compliance with all applicable laws and regulations.

Your Knowledge and Experience

• Requires a bachelor's degree or equivalent work experience, as well as thorough experience in health care, legal services or at least 7 years investigations experience

• Requires advanced knowledge of health insurance reimbursement methodologies, including ICD-10 CM, CPT and HCPCS coding

• Requires advanced knowledge and experience of Commercial, Medicare, Medi-Cal, and other government programs.

• Requires advanced knowledge of investigations typically obtained through advanced education and/or previous job experience

• Requires the ability to travel as required, including occasional overnight stays

• Requires excellent written, oral, presentation, interpersonal, and negotiation skills.

• Requires experience in fraud investigations.

• Requires the ability to read and understand medical documentation

• Requires the ability to work without written processes, procedures, or formal training program

• Requires knowledge and experience researching health plan records/systems