Investigator I

Job description

#LI-Hybrid SIU case investigation management and resolution: - Manage FWA case investigations, collaborate with federal, state and law enforcement entities, and provide applicable notifications as required. - 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. - Manage the recovery, allocation and documentation of health plan funds resulting from FWA findings. SIU allegation intake and management: - Manage the intake, documentation and resolution of FWA referrals to SIU. - Coordinate with internal and external partners on FWA allegations. - Assess needs, make recommendations and complete timely reviews in accordance with all regulatory requirements. Support SIU Operations: - Create and maintain internal policies and procedures, workflows and presentations and present as needed to internal and external entities. - Support regulatory audits and RFIs from law enforcement and federal and state entities. - Represent SIU at cross functional workgroups and meetings and present case recommendations to other applicabl...