Job Description
This description is a summary of our understanding of the job description. Click on 'Apply' button to find out more. Role Description A SIU/Fraud Investigator is responsible for working with multiple business units on coordination, identification, mitigation, and reporting of incidents and risks related to anti-fraud activities. • Conducts and/or assists with investigative tasks • Reviews referrals of potential fraud, waste, and abuse from both auto-detection programs and from claims organization, as assigned • Coordinates and performs investigations with oversight of lead investigator • Prepares responses for suspected or alleged fraud • Works closely with cross-functional leaders to ensure appropriate resolution, accurate reporting and tracking to meet client specific service level agreements • Participates as a subject matter expert during client implementations, audits and system or process development • Complies with state and federal laws to meet client contractual requirements • Conducts effective research, analysis, and accurate documentation for reporting to clients and illumifin’s leadership • Schedules surveillance once approved by the client • Conducts continuing education to Claims staff • May conduct phone calls or basic interviews with witnesses, as assigned • Assists with administration tasks relating to Fraud Services Department, as assigned • Assists with client and department reporting • Interfaces with claimants, providers and clients • Conducts telephonic interviews of members, providers, and/or additional witnesses to gather information to support investigation • Other duties as assigned Qualifications • Bachelor's degree in criminal justice, healthcare, accounting, finance or business-related field • 5+ years of experience in fraud investigation/detection or a related field that demonstrates expertise in reviewing, analyzing/developing information and making appropriate decisions • Ability to manage non-complex investigations as lead with minimum supervision or oversight • Possesses and maintains a clear understanding of investigative techniques and the laws pertaining to insurance claims and mandated fraud reporting • Demonstrated ability to use data to perform investigations • Highly motivated & detail-oriented professional with excellent analytical, organizational, verbal/written communication and follow-up skills • Skilled using Microsoft Word, Excel, Outlook, Access, PowerPoint and research tools Preferred Qualifications • Designations as: Certified Fraud Examiner, Health Care Anti-Fraud Associate or Long-Term Care Professional • Working knowledge of medical terminology • Experience in fraud detection and investigations within the long-term care or health care industry Requirements The salary range starts at $60,000 for this position. If the candidate qualifies for a senior level role adjustments will be made based on experience and qualifications. Apply tot his job