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Solis Health Plans · 1 hour ago

SIU/FWA Investigator

Doral, FL, US

Full-time

Onsite

Entry Level

$60K/yr - $70K/yr

1+ years exp

Solis Health Plans is seeking a SIU/FWA Investigator to investigate allegations of potential healthcare fraud and abuse activity. The role involves conducting investigations, performing data analysis, and preparing reports on findings for referral to relevant agencies.

Health CareHealth DiagnosticsPersonal Health

Responsibilities

Conduct investigations of potential waste, abuse, and fraud

Document activity on each case and refer issues to the appropriate party

Perform data mining and analysis to detect aberrancies and outliers in claims

Develop new queries and reports to detect potential waste, abuse, and fraud

Provide case updates on progress of investigations and coordinate with Health Plans on recommendations and further actions and/or resolutions

Assist with complex allegations of healthcare fraud

Prepare summary and/or detailed reports on investigative findings for referral to Federal and State agencies

Complete various special projects and audits

Interpret and analyze new HPMS memoranda, alerts, and regulatory guidance to assess the impact on Fraud, Waste, and Abuse (FWA) programs

Qualification

Medical claim investigationData analysisFraud detectionMedical codingSQLSASBusiness intelligence toolsBachelor’s degreeCriminal Justice knowledgeHealthcare knowledgeSoft skills