SIU Lead Investigator

About the position Optum is a global organization that delivers care, aided by technology, to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start Caring. Connecting. Growing together. You will enjoy the flexibility to telecommute from anywhere within the U.S. as you take on some tough challenges. Employees are responsible for triaging, investigating, and resolving potential instances of healthcare fraud and/or abusive conduct by medical professionals or providers. Using information from tips, complaints, external intelligence or behavior data, the medical community and law enforcement, employee's conduct confidential investigations and document relevant findings and report any illegal activities in accordance with all laws and regulations. Identify, communicate, and recover losses as deemed appropriate. These investigations may include participation in telephone calls or meetings with providers, members, clients, legal, compliance, and other investigative areas and requires adherence to state and federal compliance policies, reimbursement policies, and contract compliance. Where applicable, testimony regarding the investigation may be required in a court of law.

Responsibilities

• Perform root-cause and trend analysis and translate findings into prevention (policy recommendations, new detection rules, training opportunities, control improvements).
• Utilize appropriate documentation and tracking controls in the case tracking system to ensure compliance and auditability requirements are met
• Collaborate with SIU Investigator to apply knowledge of coding guidelines to determine validity of aberrances.
• Gather all relevant facts to articulate behavior through an Investigation Summary and compliance package.
• Collaborate with a variety of external sources to identify current and emerging patterns and schemes related for FWA
• Provide case direction and mentorship to investigators/analysts (work planning, quality checks, documentation standards, coaching on interviews and evidence development).
• Develop and deliver case presentations to leadership, clients, and compliance (case theories, evidence summaries, overpayment methodology, recommended outcomes
• Ensure confidentiality and data handling compliance (PHI/PII, minimum necessary, secure sharing, retention requirements) and coach others on the same.
• Maintain SOPs and training materials; lead calibration sessions to improve consistency in decisioning, documentation, and case outcomes.
• Track and report SIU metrics/KPIs (cycle time, recoveries, outcomes, inventory health, referral sources)
• Perform member and provider interviews, and review medical documentation as needed
• Communicate with legal, Law Enforcement, clients and business partners as needed

Requirements

• High School Diploma / GED
• Certified Professional Coder certification (CPC)
• Professional certification as a Certified Fraud Examiner (CFE), Accredited Healthcare Fraud Investigator (AHFI) or similar certification
• 5+ years of experience working in a FWA / SIU or Fraud investigations role
• 2+ years of experience within the health insurance claims industry
• 2+ years of knowledge and/or experience with medical/behavioral health codes and service delivery
• 2+ years of experience working with law enforcement or legal entities or 3+ years of investigative experience with fraud investigations
• 2+ years of experience with computer research
• 2+ years of experience with regulatory compliance
• 2+ years of experience with data analysis as it relates to financial recovery/settlements
• Intermediate level of proficiency in Microsoft Excel (pivot tables and macros) and Word (creating, editing, and saving documents)
• Familiar with CPT code terminology

Nice-to-haves

• Associate degree in the area of Criminal Justice or experience in a related field

Benefits

• comprehensive benefits package
• incentive and recognition programs
• equity stock purchase
• 401k contribution

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