SIU Investigator

Martin's Point Health Care

. Investigate suspected fraud, waste and abuse from start to finish .

Posted 11/4/2026full-timeRemote • Maine • United StatesMid-LevelSenior💰 $75,585 - $93,369 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in health care fraud investigation, including case plan development, claims data analysis, and compliance with Medicare Advantage program integrity requirements. Proficient in investigative writing and skilled in conducting interviews while maintaining the confidentiality of protected health information.

Highest-signal resume keywords

Health Care Fraud InvestigationMedicare Advantage ExperienceInvestigative WritingAdvanced Excel SkillsCase Management

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Claims Data AnalysisCase Plan DevelopmentCoding ConventionsFinancial Exposure EstimationFraud Scheme Tracking

Soft Skills

Sound JudgmentDiscretionIndependent Work

Tools & Technologies

SQLPowerBICMS-1500UB-04

Certifications & Qualifications

AHFICFECPCCCSCPMA

Industry Keywords

SIUPayment IntegrityProgram IntegrityFalse Claims ActAnti-Kickback StatuteStark LawOverpayment ReportingProtected Health Information

Tech Stack

Tools & technologies

SQL

About the role

Key responsibilities & impact

Investigate suspected fraud, waste and abuse from start to finish
Develop case plans defining allegations, scope, and estimated financial exposure
Analyze claims data to identify unusual billing patterns, estimate overpayment exposure, and support sampling and extrapolation
Review medical records and supporting documentation against CMS and TRICARE requirements, payment policies, coding guidelines, and coverage determinations
Coordinate clinical and coding review with internal departments
Conduct member and provider outreach, including investigative interviews
Maintain thorough, well-documented case files
Draft findings letters and overpayment determinations
Recommend corrective actions including provider education, prepayment review, recoupment, and network action
Prepare referrals to CMS Investigations MEDIC, the Defense Health Agency Program Integrity Office, HHS-OIG, and law enforcement
Respond to oversight entities’ requests for information
Maintain accurate case management records and contribute to SIU reporting on recoveries, cost avoidance, and referrals
Track emerging fraud schemes and help develop new analytics and edits
Support FWA compliance obligations and contribute to FWA training content
Help shape investigative standards, procedures, and cross-functional workflows for the newly established SIU
Report to the Director, Special Investigations Unit

Requirements

What you’ll need

Bachelor’s degree in criminal justice, health care administration, accounting, or other related field, or an equivalent combination of education and experience
Five or more years in health care fraud investigation, SIU, payment integrity, program integrity, or law enforcement health care fraud work required
Medicare Advantage experience required
TRICARE or other government program experience preferred
Working knowledge of Medicare Advantage program integrity requirements, the False Claims Act, the Anti-Kickback Statute, the Stark Law, and overpayment reporting obligations
Strong command of CMS-1500 and UB-04 claim formats and coding conventions
Investigative writing that can withstand legal and regulatory scrutiny
Skilled interviewer with sound judgment, discretion, and rigorous handling of protected health information (PHI)
Advanced Excel skills, SQL, PowerBI, or similar tools strongly preferred
Able to work independently and contribute in a start-up environment where procedures are still being built
At least one of the following certifications preferred: AHFI, CFE, CPC, CCS, or CPMA
This position is not eligible for immigration sponsorship

Benefits

Comp & perks

medical insurance
dental insurance
vision insurance
retirement savings with employer contributions
paid time off
volunteer time off
pie day
other employee benefits