Special investigation unit investigator job description

Our work matters. We help people get the medicine they need to feel better and live well. We do not lose sight of that. It fuels our passion and drives every decision we make.
Job Posting Title

Special Investigations Unit (SIU) Investigator (Remote)
Job Description

The Special Investigations Unit (SIU) Investigator is responsible for conducting standard investigations of potential member, and/or prescriber fraud, waste and abuse (FWA). This position conducts claims data mining, fraud analysis and auditing/monitoring activities and proactively identifies improvement opportunities in audit and investigation procedures and FWA prevention efforts ensure proper identification of potential FWA. The SIU Investigator prepares investigative reports for leadership, remediation actions, recovery efforts, internal committees and/or referral to state and federal law enforcement agencies.

Responsibilities
Develop investigative plans, documents and justification to support investigations; evaluate impact of changing circumstances or newly discovered evidence to a previously developed investigation plan; proactively communicate plans, progress and changes to department leadership and other internal or external stakeholders Evaluate reports of potential fraud in SIU and make recommendations on next steps; ensure investigative action aligns to department policy and practice; provide recommendations to audit operations and/or SIU regarding enhancements or required changes to process Adhere to evidentiary requirements in compliance with federal, state and local laws pertaining to investigations and fair claims handling practices; evaluate risk to determine how best to proceed with investigations based on the allegations, quality metrics and other performance indicators required per SIU procedures Recommend referrals to client SIUs, regulatory agencies, and/or law enforcement; recommend retention of experts or private investigators, surveillance or other expenditures to support investigations Other duties as assigned

Minimum Qualifications
Bachelor of Science/Arts in Criminal Justice, Healthcare or related area of study or the equivalent combination of education and relevant work experience; HS diploma or GED is required2 years of work experience in investigation, audit or legal to include 1 year of work experience in data or crime analysis Must be eligible to work in the United States without need for work visa or residency sponsorship

Additional Qualifications
Change agile; willing and able to adjust individual and team direction based upon changing priorities and business need while working with a high degree of autonomy Ability to think critically, problem solve and use appropriate judgement to make decisions and provide risk advice to internal and external partners while anticipating the broad impact of decisions Ability to establish trust, respect and credibility and form effective working relationships with individuals at all levels of an organization; collaborate effectively cross-functionally and with clients, law enforcement and other key stakeholders Ability to distill complex concepts or situations into concise and compelling communications Ability to interact positively and professionally during all member, prescriber and pharmacy interactions and effectively de-escalate potentially confrontational situations

Preferred Qualifications
Certified Fraud Examiner or Accredited Health Care Fraud InvestigatorNational Pharmacy Technician Certification through PTCB or ExCPT (CPhT) Licensed Practical Nurse (LPN) or Registered Nurse (RN) Prior experience in a special investigation unit Knowledge and understanding of pharmacy and medical claims processing environment

Minimum Physical Job Requirements
Constantly required to sit, use hands to handle or feel, talk and hear Frequently required to reach with hands and arms Occasionally required to stand, walk and stoop, kneel, and crouch Occasionally required to lift and/or move up to 10 pounds and occasionally lift and/or move up to 25 pounds Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus

Reporting Structure
Reports to a Manager in the Pharmacy Audit and FWA department

Potential pay for this position ranges from $55,400.00 - $83,400.00 based on location, experience and skills.

To review our Benefits, Incentives and Additional Compensation, visit our Benefits Page and click on the "Benefits at a glance" button for more detail.

Prime Therapeutics LLC is an Equal Opportunity Employer. We encourage diverse candidates to apply and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or veteran status.

The Special Investigative Unit (SIU) Investigator must either be located in Kentucky or surrounding states and willing to travel to Kentucky multiple times a year. The SIU Investigator conducts investigations to effectively pursue the prevention, investigation and prosecution of healthcare fraud and abuse, to recover lost funds, and to comply with state regulations mandating fraud plans and practices.- Routinely handles cases involving multi-disciplinary provider groups, or cases involving multiple perpetrators or intricate healthcare fraud schemes.- Investigates to prevent payment of fraudulent claims committed by insured's, providers, claimants, etc.- Researches and prepares cases for clinical and legal review.- Documents all appropriate case activity in case tracking system.- Makes referrals, both internal and external, in the required timeframe.- Facilitates the recovery of company and customer money lost as a result of fraud matters.- Assists team in identifying resources and best course of action on investigations.- Cooperates with federal, state, and local law enforcement agencies in the investigation and prosecution of healthcare fraud and abuse matters. - Demonstrates high level of knowledge and expertise during interactions and acts confidently when providing testimony during civil and criminal proceedings.- Gives presentations to internal and external customers regarding healthcare fraud matters and Aetna's approach to fighting fraud.- Provides input regarding controls for monitoring fraud related issues within the business units.- Exercises independent judgement and uses available resources and technology in developing evidence, supporting allegations of fraud and abuse.
Pay Range

The typical pay range for this role is:

Minimum: 40,600

Maximum: 81,100

Please keep in mind that this range represents the pay range for all positions in the job grade within which this position falls. The actual salary offer will take into account a wide range of factors, including location.

Required Qualifications

- Minimum three (3) year working on health care fraud, waste, and abuse investigations and audits required. - Knowledge of CPT/HCPCS/ICD coding - Knowledge and understanding of clinical issues. - Proficiency in Word, Excel, MS Outlook products, Database search tools, and use in the Intranet/Internet to research information. - Strong communication and customer service skills. - Ability to effectively interact with different groups of people at different levels in any situation. - Strong analytical and research skills. - Proficient in researching information and identifying information resources.- Ability to utilize company systems to obtain relevant electronic documentation.

COVID Requirements

COVID-19 Vaccination Requirement

CVS Health requires certain colleagues to be fully vaccinated against COVID-19 (including any booster shots if required), where allowable under the law, unless they are approved for a reasonable accommodation based on disability, medical condition, religious belief, or other legally recognized reasons that prevents them from being vaccinated.

You are required to have received at least one COVID-19 shot prior to your first day of employment and to provide proof of your vaccination status or apply for a reasonable accommodation within the first 10 days of your employment. Please note that in some states and roles, you may be required to provide proof of full vaccination or an approved reasonable accommodation before you can begin to actively work.

Preferred Qualifications

- Credentials such as a certification from the Association of Certified Fraud Examiners (CFE), an accreditation from the National Health Care Anti-Fraud Association (AHFI), or have a minimum of three years Medicaid Fraud, Waste and Abuse investigatory experience.- Billing and Coding certifications such as CPC (AAPC)and/or CCS (AHIMA)- Knowledge of Aetna's policies and procedures is a plus

Education

- A Bachelor's degree, or an Associate's degree, with an additional three years (4 years total) working on health care fraud, waste, and abuse investigations and audits required.

Business Overview

Bring your heart to CVS HealthEvery one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand - with heart at its center - our purpose sends a personal message that how we deliver our services is just as important as what we deliver.Our Heart At Work Behaviors™ support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable. We strive to promote and sustain a culture of diversity, inclusion and belonging every day. CVS Health is an affirmative action employer, and is an equal opportunity employer, as are the physician-owned businesses for which CVS Health provides management services. We do not discriminate in recruiting, hiring, promotion, or any other personnel action based on race, ethnicity, color, national origin, sex/gender, sexual orientation, gender identity or expression, religion, age, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law.

"Our Company provides a state of predictability which allows brokers and agents to act with confidence."

W. R. Berkley Corporation, a Fortune 500 Company founded in 1967, is an insurance holding company that is among the largest commercial property and casualty insurers in the United States, operating worldwide in two segments: Insurance and Reinsurance & Monoline Excess. Berkley's subsidiaries and businesses participate in niche markets requiring specialized knowledge about territory and product.

Berkley's competitive advantage lies in its decentralized operations, allowing its businesses to identify and respond quickly and effectively to changing market conditions and local customer needs. This decentralized structure provides financial accountability and incentives to local management and enables us to attract and retain the highest caliber professionals.

We have the expertise and resources to succeed and have the flexibility to anticipate, innovate and respond to whatever opportunities and challenges the future may hold.

The SIU Director is a new position at WRBC responsible for developing and executing the fraud prevention and response strategy for the enterprise. This role is a ground floor entrepreneurial opportunity to build and implement a centralized SIU function that will provide material benefit to WRBC and its subsidiaries and business units.

• Establish and maintain overall strategic direction and leadership for the SIU, ensuring that the claims organizations in the various businesses have the necessary support to identify and investigate suspicious claims and schemes in order to protect policyholder and company assets.

• Create best practices, including new investigative strategies, techniques, trends, and technologies, and collaborates with Claims Leaders regarding implementation.

• Develop and recommend key performance indicators to measure SIU success with respect to effectiveness, outcomes and efficiency.
• Conduct SIU file reviews, document case findings, and assess organizational performance.

• Interpret audit results and assist Claims Leadership teams in the development of appropriate action plans to address identified risks based on data mining and predicative analytics which detect aberrancies and outliers in claims.

• Documents all appropriate case activity in tracking system.

• Cost effectively manage outside resources and vendors to perform necessary investigative activities.

• Collaborate with Claim Leaders to develop and implement effective SIU policies, procedures and organizational structure to improve results and optimize profitability.

• Recruit and manage a team of several SIU investigators.

• Develop and maintain relationships with Claims Leadership to ensure mutual goals and expectations are met.

• Responsible for the SIU compliance functions with our clients including but not limited to scheduling and tracking clients' annual training, completing and submitting state annual anti-fraud reports, drafting and filing anti-fraud plans, maintaining carrier SIU feeder reports, etc.

• Create and facilitate Continuing Education and Anti-Fraud Awareness training.

• Identify and direct the implementation of new technologies.

• Ensure compliance with all local, state and federal regulations for fraud and abuse.

• Respond to all legal inquiries including subpoenas and court appearances.

• Minimum 15 years' experience in a SIU/Claims role, including 5 years of leadership experience.

• Experience in the identification and investigation of suspected insurance fraud, packaging and presenting suspected fraudulent claims to federal, state or local law enforcement agencies, handling SIU related compliance functions, and creating and facilitating anti-fraud awareness training.

• Possess an innovative and entrepreneurial mindset.

• Ability to organize, prioritize and manage multiple tasks; quickly and professionally respond to inquiries; effectively manage projects and lead a team; lead people and get results through others; ability to plan over a 2-3-year time span; effectively communicate with all levels of the organization; and attract, coach and develop talent.

• Advanced skills in the area of operational leadership, business strategy, predictive modeling and analytics.

• Ability to influence cooperation and collaboration in indirect reporting relationships.

• Thorough knowledge of all aspects of SIU investigations, and of SIU policies and procedures in resolving and providing directions to SIU Investigators for claims investigations, including knowledge of insurance contracts, state insurance regulations, and insurance fraud statutes.

• Experience in working with the NICB, vendors, and other industry partners to conduct investigations.

• Excellent written and verbal communication skills; confident, articulate, and professional speaking abilities (and experience).

• Advanced abilities with Microsoft Word, Excel and Outlook.

Education Requirements

+ Bachelor's degree in Accounting, Criminal Justice, Finance, Economics, Operations Management, OR considerable SIU or professional investigation experience with law enforcement agencies.

+ Certified Fraud Examiner (CFE) preferred

The Company is an equal employment opportunity employer.

COVID-19 vaccine required unless prohibited by law.


Name: WRBC Support Services

Name: IA, Urbandale - 11201 Douglas Avenue

Name: IL, Chicago - 550 W Jackson Blvd - 3rd Floor

Name: GA, Atlanta - 2 Ravinia Drive - Suite 1000

Street: 475 Steamboat Road

Industry:

Insurance

Seniority Level:

Director

Job Functions:

Other

Employment Type:

Full-Time