Senior SIU Investigator – CPC Required

Magellan Health

. Manage and own fraud, waste, and abuse investigations .

Posted 10/8/2026full-timeRemote • United StatesSenior💰 $64,285 - $102,855 per yearWebsite

Core Competencies

Role fit

Core Competencies

Use this summary to align your resume positioning with the role.

Demonstrates extensive experience in fraud, waste, and abuse investigations within the healthcare insurance sector, utilizing advanced analytical techniques and methodologies. Capable of developing and presenting comprehensive investigative reports while maintaining strong relationships with law enforcement and regulatory agencies.

Highest-signal resume keywords

Fraud InvestigationsAnalytical ThinkingCPC CertificationHealthcare Insurance ExperienceProcess Management

ATS Keywords

Tailor your resume

Applicant Tracking System Keywords

Tip: use these terms in your resume and cover letter to boost ATS matches.

Hard Skills

Fraud Investigative TechniquesData AnalysisAudit MethodologiesCase Strategy DevelopmentPerformance Metrics MeasurementCost Containment ProjectsDesk AuditsField AuditsSite VisitsPolicy Interpretation

Soft Skills

Time ManagementProblem-SolvingCommunication SkillsListening SkillsDependability

Tools & Technologies

Microsoft ExcelMicrosoft AccessMicrosoft OutlookMicrosoft WordMicrosoft PowerPoint

Certifications & Qualifications

CPCAHFICFELSSBBRN State Licensure

Industry Keywords

Fraud PreventionMedicaidMedicareProvider NetworksComplianceBehavioral HealthcareClaims ManagementInvestigative SummariesRegulatory RequirementsTask Forces

About the role

Key responsibilities & impact

Manage and own fraud, waste, and abuse investigations
Develop and present investigative results
Perform analytical and process management tasks autonomously
Serve as a corporate resource on fraud, waste, and abuse issues
Recommend cost containment projects focused on fraud prevention
Prioritize, triage, and manage workloads to meet performance, regulatory, and contractual requirements
Create investigative work plans and case strategies
Analyze data and select audit samples using various methodologies
Plan and conduct desk audits, field audits, and site visits
Review provider, member, contractual, payment policy, and Medicaid/Medicare information
Research medical policies, practices, provider characteristics, and related topics
Interview patients, providers, staff, witnesses, and experts
Prepare correspondence and preserve evidence
Maintain comprehensive case files
Triage leads and identify suspicious patterns in claims and provider enrollment data
Monitor fraud cases, schemes, investigative techniques, and industry trends
Prepare investigative summaries, conclusions, recommendations, and reports
Identify, communicate, and recover losses
Present cases to internal departments, law enforcement, and regulatory agencies
Support legal proceedings, including court testimony and civil or criminal case preparation
Negotiate and administer settlement agreements
Present to customers, prospects, conference audiences, and law enforcement
Collaborate with clients on assignment status and direction
Maintain relationships with law enforcement, regulators, task forces, SIU staff, and external contacts
Train and guide SIU investigators
Recommend and implement procedures, process flows, and industry best practices
Represent clients at task force and regulatory meetings
Measure and report performance metrics
Recommend fraud, waste, and abuse exposure reduction opportunities
Develop anti-fraud policies and procedures
Perform other assigned duties

Requirements

What you’ll need

Minimum of 7 years of experience in fraud investigations or related behavioral/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, complete dependability, and proactive problem-solving ability
Proven ability to handle fraud and abuse cases discreetly, confidentially, and professionally
Demonstrated strategic and analytical thinking skills
Ability to communicate conclusions and recommendations effectively to management
Comprehensive, practical knowledge of complex and diverse fraud investigative techniques and methodologies used in program audits
Understanding of insurance terms and policy interpretation
Ability to work to tight timelines
Ability to work independently and collaborate with peers and customers
Ability to manage and prioritize caseload with limited supervision
Strong computer skills using Microsoft Excel, Access, Outlook, Word, and PowerPoint
Bachelor's degree required; a combination of education and work experience may be considered
CPC (Certified Professional Coder) required by job title
Preferred certifications include AHFI, CFE, CPC, LSSBB, and RN state and/or compact state licensure

Benefits

Comp & perks

Short-term incentives may be available
Comprehensive benefits package
Health benefits
Life benefits
Voluntary benefits
Physical, mental, emotional and financial wellbeing perks
Tobacco-free workplace