Special Investigations Unit Analyst

Job description

The Special Investigations Unit (SIU) Analyst acts to safeguard dental benefit programs through the detection and prevention of fraud, waste, and abuse by conducting investigations into suspected insurance fraud. - Conduct full-scale investigations into cases of suspected fraud, waste, and abuse (FWA) involving providers, brokers, clients or enrollees which may require occasional travel. Investigations may involve, but are not limited to, violations of the terms of participation, group contracts, or government regulations. - Maintain and preserve all audit records, reports, letters, exhibits of findings, and other documentation related to each investigation which may include proposed refunds, disciplinary actions, and educational outreach. - Obtain and analyze information and data related to the matter(s) under investigation. Identify and evaluate unusual patterns and/or inconsistencies with submitted claims versus clinical documentation received from provider. - Refer all suspected fraud and/or misrepresentation to law enforcement agencies and assist their investigation by conducting research, providing requested documentation, and collecting evidence in support of such activities...