Key Facts

Remote From:

Full time

Mid-level (2-5 years)

English

Hard Skills

Fraud Investigation Medical Insurance Claims Root Cause Analysis Regulatory Compliance Information Privacy Behavioral Change Theories Computer-Aided Audit Tools Medical Coding Online Communication Data Visualization

Other Skills

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Report Writing
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Microsoft Excel
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Microsoft Office
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Analytical Skills
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Problem Solving
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Detail Oriented
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Non-Verbal Communication
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Teamwork

Roles & Responsibilities

Bachelor's degree in Criminal Justice or related field, or at least 3 years of insurance claims investigation or professional investigation experience
Minimum 2 years of experience in healthcare claims analysis, auditing, payment integrity, or related field
Knowledge of fraud statutes and regulations, and of federal guidelines on recoupments and anti-FWA activity
Strong analytical and problem-solving skills with attention to detail; excellent written and verbal communication; ability to handle confidential information

Requirements:

Identify and conduct investigations into known or suspected FWA with high autonomy
Manage investigative caseload from identification through resolution, including overpayment recovery and reporting for FWA recoupments and savings
Develop documentation to substantiate findings, including formal reports, graphs, audit logs, and other supporting documentation
Perform root cause analysis to inform future algorithmic identification of similar claims and associated savings

Integrity Management Services, Inc.

About Integrity Management Services, Inc.

Integrity Management Services, Inc. (IntegrityM) is a Certified Women-Owned Small Business, CMMI Level 3 appraised, ISO 9001:2015 certified, and FISMA compliant organization. IntegrityM was created to support the program integrity efforts of federal and state government programs, as well as private sector organizations. IntegrityM provides experience and expertise to government programs and private businesses supporting government programs. Results are achieved through analysis and support services such as, statistical and data analysis, compliance audit, investigation, medical review, and software solutions.At IntegrityM, we specialize in complex data and statistical analysis and auditing. Our SMEs, data analysts, and statisticians convert theory to workable, informative analysis. Our audit team has decades of experience in the design and conduct of complex audits, compliance reviews and investigations. We have a highly effective IT staff with experience and skill in creating large databases, building support systems for our auditors and investigators and establishing secure communications networks with our clients. We have written, established quality assurance procedures in place to ensure we produce quality products for our customers.We are skilled and proven at problem-solving and vigorous in seeking innovative ways to assist our clients.

Company type: SME

Founded: 2018

Company size: 51 - 200

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Job description

Job Summary

We are seeking a detail-oriented SIU Investigator to join our team. In this role, you will play a crucial role in ensuring the accuracy, compliance, and integrity of healthcare claims through comprehensive audits, analyses, and process improvements. The SIU Investigator (Analyst) primary responsibility is to detect, investigate, and produce change in aberrant behavior observed in our healthcare customer's claims and enrollment data. You will work both independently and with a team of clinical SMEs to analyze data, assess exposure, and manage investigative caseload from identification through to resolution including overpayment recovery, measuring behavior change and completing necessary reporting for FWA recoupments and savings.

Key Responsibilities

Identify and conduct investigations into known or suspected FWA with high autonomy
Develop documentation to substantiate findings, including formal reports, graphs, audit logs, and other supporting documentation.
Perform root cause analysis to inform future algorithmic identification of similar claims or cases and associated savings (i.e., help move identified case types from "pay-and-chase" to preventive edits and pre-payment activity)
Participate in the development and presentation of FWA-related education for assigned Customers
Perform coding reviews for flagged claims, to support Coding team (if applicable).

Requirements

Qualifications

Education:

Bachelor's degree in Criminal Justice or a related field, OR at least 3 years of insurance claims investigation experience or professional investigation experience with law enforcement agencies.

Experience:

Minimum of 2 years of experience in healthcare claims analysis, auditing, payment integrity, or a related field.
Knowledge of applicable fraud statutes and regulations, and of federal guidelines on recoupments and other anti-FWA activity
Experience handling confidential information and following policies, rules, and regulations
Experience with commercial, Medicare, or Medicaid claims is highly preferred.

Skills:

Strong analytical and problem-solving skills, with attention to detail and accuracy.
Excellent communication skills, both written and verbal, for effective collaboration with internal teams and external providers.
Proficiency in Microsoft Office, particularly Excel, and familiarity with claims processing or audit software is a plus.

Preferred Qualifications

Certifications: Certified Fraud Examiner (CFE), Accredited Healthcare Fraud Investigator (AHFI), Certified AML (Anti-Money Laundering) and Fraud Professional (CAFP), or similar desired.
Additional Certifications: Certified Professional Coder (CPC) or similar desired.