SIU Investigator II (Must live in Michigan or surrounding states)

Job description

Job Summary: The Special Investigations Unit (SIU) Investigator II is responsible for investigating and resolving moderate complexity allegations of healthcare fraud, waste and abuse (FWA) by medical professional, facilities, and members. Essential Functions: - Conduct investigations on own initiative or at the request of management; investigation includes data analysis, record review, cross company discussions, onsite audits, member/provider interviews, coordination with legal representative, and legal case preparation - Perform data mining utilizing fraud, waste and abuse detection software to identify aberrancies and outliers - Maintain accurate, current, and thorough case information in SIU’s case tracking system - Provide updates and reports on investigation cases’ progress and coordinates with SIU team members and management on recommendations, developing investigative plans, further actions and/or resolution - Collaborate with data analytics team and utilize RAT STATS on Statistically Valid Random Sampling Work with the clinical review team to compare medical records to bills submitted for payment looking at documentation compared to billing guidelines - Coordinate and condu...