Job Description

Develops investigative plans, documents and justification to support investigations. Investigates, reviews, and provides clinical and / or coding expertise in the application of medical and reimbursement policies within the claim adjudication process through file review. Including provider/member interviews, interpretation of state and federal mandates, applicable benefit language, medical and reimbursement policies and consideration of relevant clinical information.

Performs analysis of claims data and documentation through medical record audits to identify inappropriate billing practices and recommend next steps through extensive review of claims data, medical records, corporate policy, state/federal policy, and practice standards; applies clinical knowledge to FWA investigations to assess medical appropriateness and necessity.

Identify preventative measures and recommend changes to internal policies and procedures and/or provider practices to prevent future fraudulent and erroneous practices.

Maintains and manages daily case review assignments, with a high emphasis on quality. Provides clinical support and expertise to the other investigative areas.

Works cross functionally to build fraud & abuse investigative process. Assist SIU Manager as needed with training new hires, auditing work of junior-level employees, assisting with provider education, and answering questions from investigators


  • Bachelor's degree or equivalent work experience.
  • Active coding certification from an accredited organization (American Academy of Professional Coders or American Health Information Management Association)

Years of Experience:

  • Coding/Auditing 1-3 Years
  • Claims/Policies & Procedures 3-5 Years
  • Legal/Special investigations 3-5 Years

Work Related Experience:

Previous investigative experience, preferably in the area of healthcare fraud, waste and abuse. Experience conducting fact-finding interviews or investigations to gather information and draw conclusions from various accounts and versions of the same event. Working knowledge of medical and pharmaceutical terminology. Strong knowledge and experience in Health Plan terminology as it relates to FWA detection, prevention, and correction techniques. Previous experience in a demanding and/or fast paced setting requiring the ability to prioritize and maintain a heavy case load.

Specialized Knowledge:

  • Turning Data into Information/ADVANCED
  • Strong analytical and research skills. Proficient in researching information and identifying information resources.
  • Strong verbal and written communication skills.
  • Ability to interact with different groups of people at different levels and provide assistance on a timely basis.
  • Proficiency in Word, Excel, MS Outlook products, database search tools, and use of Internet to research information

Application Instructions

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