CareSource · 3 weeks ago
SIU Investigator III (Must live in MA or surrounding states)
United States
Full-time
Remote
Senior Level
$71K/yr - $113K/yr
5+ years expCareSource is a healthcare organization focused on investigating healthcare fraud, waste, and abuse. The SIU Investigator III role is responsible for conducting complex investigations, analyzing data, and collaborating with various teams to ensure compliance with healthcare laws and regulations.
Health CareMedicalNon Profit
Responsibilities
Develop, coordinate and conduct strategic fact-driven investigative projects including business process review, execution of investigative activities, and development of investigation outcome recommendations
Manage the development, production, and validation of reports generated from detailed claims, eligibility, pharmacy, and clinical data and translate analytical findings into actionable items
Manage strategic investigative plan and drive investigative outcome for the team
Ensure quality outcomes for investigative team through auditing and oversight
Prioritize, track, and report status of investigations
Report identified corporate financial impact issues
Use concepts and knowledge of coding guidelines to analyze complex provider claim submissions
Research, comprehend and interpret various state specific Medicaid, federal Medicare, and ACA/Exchange laws, rules and guidelines
Identify, research and comprehend medical standards, healthcare authoritative sources and apply knowledge to investigative approach
Collaborate with data analytics team and utilize RAT STATS on Statistically Valid Random Sampling
Coordinate and conduct on-site and desk audits of medical record reviews and claim audits
Manage and decision claims pended for investigative purposes
Maintain a working knowledge of all state and federal laws, rules, and billing guidelines for various provider specialty types
Prepare and conduct in-depth complex interviews relevant to investigative plan
Execute and manage provider formal corrective action plans
Participate in meetings with operational departments, business partners, and regulatory partners to facilitate investigative case development
Participate in meetings with Legal General Counsel to drive case legal actions, formal corrective actions, negotiations with recovery efforts, settlement agreements, and preparation of evidentiary documents for litigation
Present, support, and defend investigative research to seek approval for formal corrective actions
Establish and maintain relationships with Federal and State law enforcement agencies, task force members, other company SIU staff and external contacts involved in fraud investigation, detection and prevention
SME in the designated market and ability to apply external intelligence to their analysis and case development
Develop and present internal and external formal presentations, as needed
Attend fraud, waste, and abuse training/conferences, as needed
Support regulatory fraud, waste, and abuse reports to federal and state Medicare/Medicaid agencies
Manage and maintain sensitive confidential investigative information
Maintain compliance with state and federal laws and regulations and contracts
Adhere to the CareSource Corporate Compliance Plan and the Anti-Fraud Plan
Assist in Federal and State regulatory audits, as needed
Perform any other job-related instructions, as requested
Qualification
Required
Bachelor's Degree or equivalent years of relevant work experience in Health-Related Field, Law Enforcement, or Insurance
Minimum of five (5) years of experience in healthcare fraud investigations, medical coding, pharmacy, medical research, auditing, data analytics or related field
One of the following certifications is required: Accredited Healthcare Fraud Investigator (AHFI) or Certified Fraud Examiner (CFE)
Intermediate proficiency level in Microsoft Office to include Outlook, Word, Excel, Access, and PowerPoint
Effective listening and critical thinking skills and the ability to identify gaps in logic
Strong interpersonal skills, high level of professionalism, integrity and ethics in performance of all duties
Excellent problem solving and decision making skills with attention to details
Background in research and drawing conclusions
Ability to perform intermediate data analysis and to articulate understanding of findings
Ability to work under limited supervision with moderate latitude for initiative and independent judgment
Ability to manage demanding investigative case load
Ability to develop, prioritize and accomplish goals
Self-motivated, self-directed
Strong written skills with ability to compose detailed investigative reports and professional internal and external correspondences
Ability to maintain compliance with state and federal laws and regulations and contracts
Adhere to the CareSource Corporate Compliance Plan and the Anti-Fraud Plan
Preferred
Master's Degree (e.g., criminal justice, public health, mathematics, statistics, health economics, nursing)
Certified Professional Coder (CPC)
NHCAA or other fraud and abuse investigation training
Knowledge of Medicaid, Medicare, healthcare rules
Background in medical terminology, CPT, HCPCS, ICD codes or medical billing
Complex project management skills
Presentation experience, beneficial
Benefits
You may qualify for a bonus tied to company and individual performance
Substantial and comprehensive total rewards package
Company
CareSource
CareSource provides managed care services to Medicaid beneficiaries.
1001-5000 employees
Funding
Current Stage
Late StageLeadership Team
Erhardt Preitauer
President & Chief Executive Officer
Larry Smart
Chief Financial Officer
Recent News
Dayton Daily News
2025-12-17
Dayton Daily News
2025-11-19
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