Analyst – Special Investigative Unit

1-3 years of Investigative experience in the area of healthcare fraud, waste and abuse
Strong knowledge of medical terminology/CPT/HCPCS coding.
Advanced skills with Microsoft Excel
Experience in healthcare/medical insurance claims investigation or professional/clinical experience
Background with law enforcement agencies involving economic or insurance related matters; or professional investigation experience involving economic or insurance related matters; or an authorized medical professional to evaluate medical related claims
Strong analytical and research skills
Proficient in researching information and identifying information resources
Proficiency in Word, MS Outlook products, Database search tools, and use in the Intranet/Internet to research information
Strong verbal and written communication skills
Strong customer service skills
Ability to interact with different groups of people at different levels and provide assistance on a timely basis
Ability to utilize company systems to obtain relevant electronic documentation

Conducts investigations of known or suspected acts of healthcare fraud, waste, and abuse
Communicates with federal, state, and local law enforcement agencies as appropriate in matters pertaining to the prosecution of specific healthcare fraud cases
Investigates to prevent payment of fraudulent, abusive, or otherwise improperly billed claims submitted by providers, members, and others
Facilitates the recovery of company and customer monetary losses
Provides input regarding controls for preventing or monitoring fraud related issues within the business units
Delivers educational programs designed to promote deterrence and detection of fraud and minimize losses to the company
Maintains open communication with constituents within and external to the company
Uses available resources and technology in developing evidence, supporting allegations of fraud, waste, and abuse
Researches and prepares cases for clinical and legal review
Documents all appropriate case activity in tracking system
Makes referrals, both internal and external, in the required timeframe
Exhibits behaviors outlined in Employee Competencies
Exhibits behaviors outlined in SIU Investigator Competencies
May include travel to testify in court proceedings or training if necessary