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Corporate Functions & Operations WellCare - Clinical Compliance Careers

SIU Investigator - Senior Job

Full Job Title: SIU Investigator Senior

Job Number: 1701642

Location: Louisville, KY

Date Posted: 8-24-2017

The Senior Investigator investigates cases of health care fraud and abuse within the Special Investigations Unit (SIU). He or she will assume responsibility for higher profile and more complex cases and will also be expected to serve as a resource to more junior SIU staff.

Essential Functions:
  • Manages large caseloads and investigates allegations and complex issues pertaining to potential health care fraud by providers or members.
  • Documents investigations, including preliminary and final case reports for both internal tracking and regulatory reporting purposes.
  • Proactively identifies trends and aberrant activity to generate leads for fraud investigations and analyzes claims data to detect fraudulent activity.
  • Supports senior compliance staff and legal counsel in all phases of investigation and litigation.
  • Prepares cases for referral to law enforcement officials for prosecution.
  • Develops and maintains strong working relationships with associates and regulators.
  • Testify in criminal and civil matters as needed.
  • Conduct special assignments as needed.
  • Trains associates regarding the activities of the Special Investigation Unit.
  • Provides training, mentors and oversight of junior staff on casework and other SIU activities.
  • Perform other duties as assigned.
Additional Responsibilities:Candidate Education:
  • Required A Bachelor's Degree in a related field or equivalent combination of education and experience required
Candidate Experience:
  • Required 5 years of experience in Investigations and healthcare fraud-related investigations combined
  • Medical investigative experience with a focus on Medicaid and Medicare Preferred.
Candidate Skills:
  • Advanced Knowledge of community, state and federal laws and resources
  • Advanced Other In-depth knowledge of government programs, the managed care industry, federal, state, civil and criminal statutes, and Medicare & Medicaid laws and requirements.
  • Advanced Ability to multi-task
  • Advanced Demonstrated written communication skills
  • Advanced Demonstrated organizational skills
  • Advanced Ability to work in a fast paced environment with changing priorities
  • Intermediate Demonstrated leadership skills
Licenses and Certifications:
A license in one of the following is required:
  • Preferred Other Accredited Healthcare Fraud Investigations (AHFI) or Certified Fraud Examiner (CFE)
Technical Skills:
  • Required Intermediate Other Knowledge and understanding of claims processing systems and medical claims coding preferred
  • Preferred Intermediate Other Computer literate (MS Office, Excel, etc.)

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Last Updated On: 12/9/2015