Investigator II

Job description

#LI-Hybrid - SIU case investigation management, resolution and prevention: - Manage complex FWA case investigations, collaborate with federal, state and law enforcement entities, and provide applicable notifications as required. - Conduct pro-active FWA case investigations and resolutions. - Maintain extensive documentation and evidence for SIU cases. - Recommend and implement preventive measures to combat FWA schemes including, but not limited to provider education, policies, claims edits and payment suspensions. - Conduct and lead on-site provider audits and interviews to support complex FWA case investigations. - Manage the recovery, allocation and documentation of health plan funds resulting from FWA findings. Support SIU Operations: - Create and maintain internal policies and procedures, workflows and presentations and present as needed to internal and external entities. - Coordinate and manage regulatory audit requests and RFIs from law enforcement and federal and state entities. - Represent SIU at cross functional workgroups and meetings and present case recommendations and preventive solutions to Management and other applicable business areas including, but not limited to L...