Special Investigation Unit (SIU) Fraud, Waste and Abuse Investigator

Special Investigation Unit (SIU) Fraud, Waste and Abuse Investigator
Wheeling, WV Charleston, WV
Full-Time
Compliance
Manager of Department

 

The SIU FWA Investigator is responsible for investigating allegations of healthcare fraud, waste, and abuse across multiple lines of business.

The Investigator will conduct full investigations which may include data analysis, research, contract review, medical records review, interviews of patients, witnesses, and providers, site visits, consulting with other subject matter experts, coordination with law enforcement or regulatory agencies, and other necessary investigative activities. 

The Investigator will create plans of investigation and determine scope, timing, and direction of the investigations, ensuring they are completed timely and in a lawful, ethical, and appropriate manner. 

  1. Bachelor's degree in Business, Criminal Justice, or other fraud-related field; or a Bachelor's degree in any field and a Master's Degree in any fraud-related discipline. (Four [4] years of relevant experience as described below may be substituted for the required education.).
  2. At least 2 years of relevant experience such as: SIU, medical claim investigation, healthcare program integrity, or general investigations.
  3. Working knowledge of Microsoft Office Suite applications.
  4. Ability to read and understand laws, policies, and regulations and apply them appropriately.
  5. Strong analytical skills.
  6. Strong problem-solving skills.
  7. Detail oriented, with a high level of accuracy.
  8. Effective written and oral communication skills, including the ability to explain technical information to non-technical audiences.
  9. Ability to plan and execute projects independently and meet tight deadlines.
  10. Interpersonal skills, and the ability to elicit cooperation.
  11. Ability to testify credibly, confidently, and competently.
  12. Ability to conduct field work.
  13. Inquisitiveness, tenacity, and healthy skepticism, with the ability to remain objective and make sound decisions.
  14. Ability and desire to work with confidence, initiative, and autonomy while also being a competent and reliable team member.
  15. High ethical standards and professionalism.
  16. Valid, non-restricted driver's license.

  1. Certification as an AHFI, CFE, or other relevent discipline.
  2. Working knowledge of the law and the rules of evidence.
  3. Experience with claims processing systems.
  4. Knowledge of coding, reimbursement, and claims processing.
  5. Completion of Reid Interviewing and Interogation course, or other deception detection training.

Employment Documents

EEO

Or, if you are interested in a fast-paced career with us, please send resume with salary requirements to:

HR Department 
1110 Main Street
Wheeling, WV 26003-2704
hr@healthplan.org