Magellan Health
SIU Program Integrity Investigator - Remote (In Idaho)
Magellan Health, Boise, Idaho, United States, 83708
SIU Program Integrity Investigator - Remote (In Idaho)
Join to apply for the
SIU Program Integrity Investigator - Remote (In Idaho)
role at
Magellan Health
Overview This position is responsible for comprehensive management and ownership of fraud, waste and abuse investigations including development and presentation of investigative results. The investigator carries out analytical and process‑management tasks with a high degree of autonomy and serves as a corporate resource on fraud, waste and abuse issues, recommending cost‑containment projects that emphasize fraud prevention.
Responsibilities
INVESTIGATIONS
Prioritize, triage and manage workload to meet internal performance metrics, regulatory and contractual requirements.
Use independent judgment to create investigative work plans and develop case strategies based upon analysis of referral data and contractual/regulatory requirements.
Analyze data and select audit samples using various sampling methodologies.
Plan and conduct desk audits, field audits and/or site visits.
Collect and analyze information to evaluate facts and circumstances through an extensive review of data from professional and facility providers, member data, contractual relationships, payment policies, Medicaid/Medicare rules and statutes, etc.
Conduct research on medical policies and practices, provider characteristics, and related topics.
Interview patients, providers, provider staff, and other witnesses/experts.
Prepare correspondence.
Obtain and preserve physical and documentary evidence to support investigations.
Maintain comprehensive case files.
FRAUD, WASTE AND ABUSE DETECTION
Triage and prioritize leads from internal and external sources.
Use knowledge of healthcare coding conventions, fraud schemes, and general areas of vulnerability, reimbursement methodologies, and relevant laws to find suspicious patterns in claims data, provider enrollment data, and other sources.
Remain up to date on published fraud cases, schemes, investigative techniques and methodologies, and industry trends.
PACKAGING OF FINDINGS AND RECOMMENDATIONS
Organize data and prepare a written summary of investigative steps, conclusions, recommendations with attention to detail and a high level of accuracy.
Prepare clear and concise investigatory reports to support findings of potential fraud, waste and abuse.
CASE RESOLUTION
Identify, communicate and recover losses as deemed appropriate.
Present case to internal department(s), law enforcement and/or regulatory agencies.
Support legal proceedings as needed, including testifying in court or working with law enforcement personnel to prepare cases for civil or criminal actions.
Negotiate settlement agreements with subjects and/or attorneys.
Assist in preparation, execution, and follow‑up of settlement agreement terms.
CUSTOMER INTERACTIONS
Make presentations to customers, prospects, conference audiences, and law enforcement.
Collaborate, consult, and coordinate regularly with clients on the status and direction of assignments.
Develop and maintain contacts/liaisons with law enforcement, regulatory agencies, task force members, other company SIU staff and external contacts involved in fraud investigation, detection and prevention.
MISCELLANEOUS DUTIES
Represent client at industry task force meetings and meetings with regulatory agencies.
Measure and report performance metrics.
Identify opportunities and make recommendations for reduction of exposure to fraud, waste and abuse.
Consult on anti‑fraud policies and procedures.
Other duties as assigned.
Other Job Requirements
Minimum of five years of experience in fraud investigations, related behavioral or medical healthcare insurance experience in claims, clinical, auditing, compliance, provider networks, management, or project planning.
Demonstrated abilities in time management and establishing priorities.
Strong listening and observation skills.
Impeccable work ethic, completely dependable, and proactive; a problem solver.
Proven ability to effectively handle cases of fraud and abuse in a discreet, confidential, and professional manner.
Demonstrated strategic and analytical thinking skills, with ability to effectively communicate conclusions and recommendations to management.
Comprehensive, practical knowledge of complex and diverse fraud investigative techniques and methodologies utilized in program audits.
Understanding of insurance terms and policy interpretation.
Ability to work to tight timelines when necessary.
Works independently; collaborates well with peers and customers.
Demonstrated ability to manage and prioritize case load with limited supervision.
Strong computer skills consisting of Microsoft Excel, Access, Outlook, Word, and PowerPoint.
General Job Information
Title: SIU Program Integrity Investigator - Remote (In Idaho)
Grade: 24
Work Experience – Required: Fraud Investigations
Work Experience – Preferred: None specified
Education – Required: Bachelor’s degree or equivalent combination of education and experience
Education – Preferred: None specified
License and Certifications – Required: None specified
License And Certifications – Preferred: AHFI, CFE, CPC, LSSBB, RN, or equivalent
Salary Minimum: $58,440
Salary Maximum: $93,500
Benefits & Compensation This information reflects the anticipated base salary range for this position based on current national data. Minimums and maximums may vary based on location. Actual pay will be adjusted based on an individual's skills, experience, education, and other job‑related factors permitted by law. The position may be eligible for short‑term incentives as well as a comprehensive benefits package. Magellan offers a broad range of health, life, voluntary and other benefits and perks that enhance your physical, mental, emotional and financial wellbeing.
Magellan Health, Inc. is proud to be an Equal Opportunity Employer and a Tobacco‑free workplace. EOE/M/F/Vet/Disabled.
Every employee must understand, comply with and attest to the security responsibilities and security controls unique to their position; and comply with all applicable legal, regulatory, and contractual requirements and internal policies and procedures.
#J-18808-Ljbffr
SIU Program Integrity Investigator - Remote (In Idaho)
role at
Magellan Health
Overview This position is responsible for comprehensive management and ownership of fraud, waste and abuse investigations including development and presentation of investigative results. The investigator carries out analytical and process‑management tasks with a high degree of autonomy and serves as a corporate resource on fraud, waste and abuse issues, recommending cost‑containment projects that emphasize fraud prevention.
Responsibilities
INVESTIGATIONS
Prioritize, triage and manage workload to meet internal performance metrics, regulatory and contractual requirements.
Use independent judgment to create investigative work plans and develop case strategies based upon analysis of referral data and contractual/regulatory requirements.
Analyze data and select audit samples using various sampling methodologies.
Plan and conduct desk audits, field audits and/or site visits.
Collect and analyze information to evaluate facts and circumstances through an extensive review of data from professional and facility providers, member data, contractual relationships, payment policies, Medicaid/Medicare rules and statutes, etc.
Conduct research on medical policies and practices, provider characteristics, and related topics.
Interview patients, providers, provider staff, and other witnesses/experts.
Prepare correspondence.
Obtain and preserve physical and documentary evidence to support investigations.
Maintain comprehensive case files.
FRAUD, WASTE AND ABUSE DETECTION
Triage and prioritize leads from internal and external sources.
Use knowledge of healthcare coding conventions, fraud schemes, and general areas of vulnerability, reimbursement methodologies, and relevant laws to find suspicious patterns in claims data, provider enrollment data, and other sources.
Remain up to date on published fraud cases, schemes, investigative techniques and methodologies, and industry trends.
PACKAGING OF FINDINGS AND RECOMMENDATIONS
Organize data and prepare a written summary of investigative steps, conclusions, recommendations with attention to detail and a high level of accuracy.
Prepare clear and concise investigatory reports to support findings of potential fraud, waste and abuse.
CASE RESOLUTION
Identify, communicate and recover losses as deemed appropriate.
Present case to internal department(s), law enforcement and/or regulatory agencies.
Support legal proceedings as needed, including testifying in court or working with law enforcement personnel to prepare cases for civil or criminal actions.
Negotiate settlement agreements with subjects and/or attorneys.
Assist in preparation, execution, and follow‑up of settlement agreement terms.
CUSTOMER INTERACTIONS
Make presentations to customers, prospects, conference audiences, and law enforcement.
Collaborate, consult, and coordinate regularly with clients on the status and direction of assignments.
Develop and maintain contacts/liaisons with law enforcement, regulatory agencies, task force members, other company SIU staff and external contacts involved in fraud investigation, detection and prevention.
MISCELLANEOUS DUTIES
Represent client at industry task force meetings and meetings with regulatory agencies.
Measure and report performance metrics.
Identify opportunities and make recommendations for reduction of exposure to fraud, waste and abuse.
Consult on anti‑fraud policies and procedures.
Other duties as assigned.
Other Job Requirements
Minimum of five years of experience in fraud investigations, related behavioral or medical healthcare insurance experience in claims, clinical, auditing, compliance, provider networks, management, or project planning.
Demonstrated abilities in time management and establishing priorities.
Strong listening and observation skills.
Impeccable work ethic, completely dependable, and proactive; a problem solver.
Proven ability to effectively handle cases of fraud and abuse in a discreet, confidential, and professional manner.
Demonstrated strategic and analytical thinking skills, with ability to effectively communicate conclusions and recommendations to management.
Comprehensive, practical knowledge of complex and diverse fraud investigative techniques and methodologies utilized in program audits.
Understanding of insurance terms and policy interpretation.
Ability to work to tight timelines when necessary.
Works independently; collaborates well with peers and customers.
Demonstrated ability to manage and prioritize case load with limited supervision.
Strong computer skills consisting of Microsoft Excel, Access, Outlook, Word, and PowerPoint.
General Job Information
Title: SIU Program Integrity Investigator - Remote (In Idaho)
Grade: 24
Work Experience – Required: Fraud Investigations
Work Experience – Preferred: None specified
Education – Required: Bachelor’s degree or equivalent combination of education and experience
Education – Preferred: None specified
License and Certifications – Required: None specified
License And Certifications – Preferred: AHFI, CFE, CPC, LSSBB, RN, or equivalent
Salary Minimum: $58,440
Salary Maximum: $93,500
Benefits & Compensation This information reflects the anticipated base salary range for this position based on current national data. Minimums and maximums may vary based on location. Actual pay will be adjusted based on an individual's skills, experience, education, and other job‑related factors permitted by law. The position may be eligible for short‑term incentives as well as a comprehensive benefits package. Magellan offers a broad range of health, life, voluntary and other benefits and perks that enhance your physical, mental, emotional and financial wellbeing.
Magellan Health, Inc. is proud to be an Equal Opportunity Employer and a Tobacco‑free workplace. EOE/M/F/Vet/Disabled.
Every employee must understand, comply with and attest to the security responsibilities and security controls unique to their position; and comply with all applicable legal, regulatory, and contractual requirements and internal policies and procedures.
#J-18808-Ljbffr