Special Investigations Unit (SIU) Investigator - Lumen Solutions Group, Inc.

Purpose:

The SIU Investigator plays a crucial role in reducing and recuperating losses by detecting, investigating, and resolving cases of fraud, waste, and abuse. This position focuses on identifying and resolving low to medium levels of fraud schemes, resulting in significant savings and recovery of funds.

Key Responsibilities:

• Investigation and Analysis:

  • Independently conduct low to medium-level investigations into suspected fraud, waste, and abuse.
  • Collaborate with team members to develop and execute investigative plans, which may include audits of financial business records, medical data, claims, and provider/subscriber history.
  • Utilize company anti-fraud software, Excel, and other analytical tools to proactively identify potential cases.

• Documentation and Reporting:

  • Prepare detailed documentation to substantiate findings, including formal reports, spreadsheets, graphs, and audit logs.
  • Maintain organized case files with accurate documentation outlining investigative steps, synopses, and findings, ensuring compliance with discoverability requirements.

• Claims Recovery:

  • Initiate claim adjustments, voucher deductions, and voluntary refunds to recover funds, following established processes.
  • Record recoveries and savings to support unit goals.

• Special Projects:

  • Participate in special projects as assigned by management to support the objectives of the Special Investigations Unit.

Qualifications:

Education:

• Bachelor’s Degree in a relevant field; in lieu of a degree, an additional 4 years of relevant experience is required along with the necessary work experience.

Experience:

• Minimum of 2 years in insurance, investigations, healthcare, nursing, or law enforcement.

Preferred Qualifications:

• Credential in a healthcare or investigations-related area, such as:
  • Certified Fraud Examiner (CFE)
  • Accredited Health Fraud Investigator (AHFI)
  • RN/LPN
  • Certified Professional Coder (CPC)
• Knowledge of ICD-10 and CPT® codes, medical terminology, and claims processing within the healthcare industry.

Knowledge, Skills, and Abilities (KSAs):

• Proficient knowledge of laws related to public and insurance funds.
• Excellent written and verbal communication skills.
• Strong analytical skills with the ability to recognize, analyze, and solve various problems.
• Ability to maintain effective interpersonal relationships.