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Description:

The role of the Special Investigations Unit SIU Investigator is to assist in the reduction and recuperation of losses through the detection investigation and resolution of low to medium levels fraud waste and abuse schemes resulting in the savings and recovery of funds Responsibilities Independently conduct low to medium level investigations and provide support as part of an assigned team to all levels low to medium investigations of suspected fraud waste and abuse. In conjunction with assigned team or management develop and execute investigative plans that may include performance of audits of financial business records provider and subscriber medical data claims systems reports medical records analysis of contract documents provider/subscriber claims history benefits external data banks and other documents to determine the possible existence of fraud and/or abuse. Provide support for offsite audits/investigations and interviews when requested. Research provider/subscriber claims activity operations manuals data systems medical policies job duties and group benefit contracts to identify control deficiencies and non-compliance. Investigator will develop documentation to substantiate finding including formal reports spreadsheets graphs audit logs use of anti-fraud software and appropriately sourced reference materials. Must ensure audits and investigations are timely effective and result in an overall achievement of unit goals. Investigator researches and analyzes claims data using company anti-fraud software Excel and other tools to proactively identify new potential cases. Investigator will develop documentation that supports conclusions recommendations and substantiates findings including formal correspondence audit reports spreadsheets graphs audit logs anti-fraud software analysis and appropriately sourced reference materials. Investigator ensures timely maintenance and organization of case file documentation with a high level of detail and accuracy that clearly and concisely outlines investigative steps case synopses and findings and to preserve as potentially discoverable material Initiate claim adjustments voucher deducts and voluntary refunds in order to recover funds. Record recoveries and savings following established processes. Perform special projects as assigned by management to meet the needs of the Special Investigations Unit. Qualifications Education Level: Bachelor's Degree Experience: 2 years insurance investigative health care nursing or law enforcement. In lieu of a Bachelor's degree an additional 4 years of relevant work experience is required in addition to the required work experience. Preferred Qualifications Credential in a health care or investigations related area such as Certified Fraud Examiner CFE Accredited Health Fraud Investigator AHFI RN/LPN or Certified Professional Coder CPC. Knowledge of ICD 10 and CPT Codes medical terminology extensive training in claims and subscriber customer service methods and previous experience in the health care industry. Knowledge Skills and Abilities KSAs Proficiency Knowledge of laws that pertain to public and insurance funds - Proficient Excellent communication skills both written and verbal. - Proficient Ability to recognize analyze and solve a variety of problems. - Proficient Ability to maintain effective interpersonal relationships - Proficient

Experience Level:

Intermediate Level

About TEKsystems:

We're partners in transformation. We help clients activate ideas and solutions to take advantage of a new world of opportunity. We are a team of 80,000 strong, working with over 6,000 clients, including 80% of the Fortune 500, across North America, Europe and Asia. As an industry leader in Full-Stack Technology Services, Talent Services, and real-world application, we work with progressive leaders to drive change. That's the power of true partnership. TEKsystems is an Allegis Group company.

The company is an equal opportunity employer and will consider all applications without regards to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law.