SIU Investigator

Accountabilities:

- Conduct fraud, waste, and abuse investigations using referrals, claims data, medical records, interviews, data analytics, provider information, and other investigative resources to identify potential misconduct and support case resolution.

- Review healthcare claims, medical records, provider billing practices, enrollment information, financial records, coding documentation, and related evidence to identify potential fraud, waste, abuse, overpayments, and compliance concerns.

- Analyze, document, and maintain investigative activities, findings, recommendations, and case outcomes in accordance with established procedures, regulatory requirements, service standards, and investigative protocols.

- Prepare investigative reports, case summaries, referrals, and supporting documentation for internal stakeholders, regulatory agencies, law enforcement entities, and other authorized parties as appropriate.

- Collaborate with compliance, legal, provider and payment integrity teams, internal business partners, and external agencies to coordinate investigations, corrective actions, recoveries, and case resolution efforts.

- Support audits, overpayment identification and recovery activities, regulatory responses, special projects, and broader program integrity initiatives.

- Monitor emerging fraud schemes, billing irregularities, and industry trends that may create risks for healthcare programs, recommending appropriate actions for further investigation or review.

- Support investigative case progression through onsite audits, provider or member visits, drive-by activities, interviews with members, providers, witnesses, and other relevant investigative activities.

- Maintain compliance with applicable federal and state regulations, contractual obligations, privacy requirements, investigative standards, and organizational policies.

- Maintain accurate investigative records and ensure all activities and communications are handled in accordance with applicable policies and standards.

- Perform additional investigative and program integrity duties as assigned.

Requirements:

- Bachelor’s degree in Business, Criminal Justice, Healthcare Administration, Public Health, or a related field, or equivalent relevant experience.

- At least 2 years of experience in fraud, waste, and abuse investigations, healthcare investigations, claims auditing, payment integrity, healthcare compliance, law enforcement investigations, or a related investigative discipline.

- Experience analyzing healthcare claims, medical records, provider billing and coding documentation, provider data, financial information, or similar records to support investigations and case development is preferred.

- Strong analytical and investigative skills, with the ability to identify inconsistencies, assess evidence, recognize patterns, and develop well-supported findings.

- Strong written and verbal communication skills, including the ability to prepare clear investigative reports and communicate findings to internal and external stakeholders.

- Excellent attention to detail and organizational skills, with the ability to manage multiple cases, documentation requirements, deadlines, and investigative priorities.

- Ability to work collaboratively with compliance, legal, payment integrity, healthcare providers, regulatory agencies, and other stakeholders while maintaining appropriate confidentiality.

- Sound judgment and problem-solving abilities, with a commitment to regulatory compliance, investigative integrity, and accurate case documentation.

- Experience conducting interviews, onsite investigations, audits, or field-based investigative activities is advantageous.

- AHFI, CFE, CPC, CPMA, or another relevant investigative, auditing, healthcare, or compliance certification is preferred.

Benefits:

- Salary: $56,200–$101,000 USD per year, with actual compensation determined by skills, experience, education, job-related factors, and employment status.

- Additional Compensation: Total compensation may include additional incentive opportunities where applicable.

- Healthcare: Comprehensive health insurance benefits designed to support employees and their families.

- Retirement: 401(k) plan and stock purchase opportunities.

- Paid Time Off: Paid time off and holidays to support rest, personal needs, and work-life balance.

- Tuition Support: Tuition reimbursement opportunities to encourage continued professional development.

- Flexible Work: Flexible work arrangements that may include remote, hybrid, field, or office-based schedules depending on role and business needs.

- Purpose-Driven Work: Opportunity to contribute to healthcare program integrity and help protect resources that support individuals, families, and communities.

- Inclusive Workplace: Commitment to diversity, equity, inclusion, and equal employment opportunity.

How Jobgether works:
We use an AI-powered matching process to ensure your application is reviewed quickly, objectively, and fairly against the role's core requirements. Our system identifies the top-fitting candidates, and this shortlist is then shared directly with the hiring company. The final decision and next steps (interviews, assessments) are managed by their internal team.
We appreciate your interest and wish you the best!
 Why Apply Through Jobgether? 
 
Data Privacy Notice: By submitting your application, you acknowledge that Jobgether will process your personal data to evaluate your candidacy and share relevant information with the hiring employer. This processing is based on legitimate interest and pre-contractual measures under applicable data protection laws (including GDPR). You may exercise your rights (access, rectification, erasure, objection) at any time.
 
 
#LI-CL1