Investigator

• 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

Explore SIU Investigator at Martin's Point Health Care. Review requirements and application details.