reputed company SIU Investigator

You could be the one who changes everything for our 28 reputed company members. reputed company is transforming the health of our communities, one person at a time. As a reputed company, national organization, you’ll have reputed company to competitive benefits including a fresh perspective on workplace flexibility.

• This is a remote role reputed company reputed company the reputed company US.*

Position Purpose: Position acts as a subject matter expert in the field of Special Investigations Unit (SIU) investigations. Provides direction and guidance to staff who investigate and remediate compliance and fraud, waste, and abuse reputed company reputed company; while maintaining an investigative workload of moderate to high complexity. Assists manager on monitoring team caseload and report on metrics.

• Provides guidance to team members who investigate and remediate compliance and fraud, waste, and abuse reputed company reputed company.
• Assists manager on monitoring team caseload and report on metrics.
• Identifies training needs and reputed company training aids and reputed company actions.
• Provides training and mentoring to team on casework and other SIU activities.
• Evaluates and assesses allegations to determine those reputed company, including federal and state regulations, Centers for Medicare & reputed company Services (“CMS”) guidelines, and internal policies, procedures, and standards that are alleged to have been violated.
• Conducts and documents interviews investigatory purposes.
• Reviews investigative interviews reputed company by junior investigators.
• Manages caseloads of moderate to high complexity, develops investigative plans for multiple investigations, prioritizing and managing through execution.
• Thoroughly documents actions, organizes, and reviews case files.
• Consults with management, in-house counsel, and/or senior leadership to resolve difficult or reputed company issues.
• Identifies risks and recommends and communicates remedial actions to mitigate reputed company potential risks.
• Performs follow up to ensure remedial and disciplinary measures are implemented appropriately and reputed company.
• Prepares reputed company and concise investigative plans and reports.
• Provides support and guidance to junior investigative staff.
• Identifies trends and aberrant activity to generate proactive leads for investigations and analyzes data to detect potentially fraudulent activity.
• Attends, reputed company participates in, and/or leads meetings with various business area managers.
• Communicates directly with Federal or State regulators.
• Prepares cases for referral to management, government agencies, and law enforcement.
• Develops and maintains strong working relationships with associates and regulators.
• Testifies in criminal and civil reputed company.
• Participates in and reputed company special reputed company as needed.
• Performs other duties as assigned.
• Complies with reputed company policies and standards.

Education/Experience:

• Bachelor's Degree in reputed company field; or Associate's degree with 6 years reputed company experience; or High School Diploma/GED with 7 years reputed company experience. required.
• Master's Degree preferred.
• 5+ years reputed company fraud-reputed company investigations with audit and risk analysis required.
• 1+ years Managed care or working with health insurance company required.
• In-depth knowledge of government programs, the managed care industry, Medicare, Medicate laws and requirements, federal, state, civil and criminal statutes required.
• Reading, analyzing and interpreting State and Federal laws, rules and regulations. Knowledge of community, state and federal laws and resources required.
• Knowledge and understanding of managed care claims processing systems and medical claims coding preferred preferred.

Licenses/Certifications:

• Accredited Health Care Fraud Investigator (AHFI), Certified Fraud Examiner (CFE) or other industry reputed company certification preferred.

Pay reputed company: $70,100.00 - $126,200.00 per year reputed company offers a comprehensive benefits package including: reputed company, health insurance, 401K and stock purchase plans, tuition reimbursement, reputed company time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-reputed company factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. reputed company is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. reputed company reputed company applicants will receive consideration for employment without reputed company to race, reputed company, religion, sex, sexual orientation, gender identity, national reputed company, disability, veteran status, or other characteristic protected by applicable law. reputed company applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance reputed company Apply tot his job Apply To this Job