[Hiring] Special Investigations Unit (SIU) Analyst II @CoventBridge Group

Role Description

The SIU Analyst II conducts end to end fraud, waste and abuse investigations on referred cases that have been triaged for investigative handling. This role is responsible for developing the investigative plan, gathering and analyzing data, documenting findings and producing clear, defensible case files and reports to support recoveries, administrative actions, referrals and other program outcomes. The SIU Analyst II works independently on moderately complex cases, collaborates with clinical and analytics partners as needed and ensures investigative activities meet regulatory requirements, policy standards and evidentiary expectations. This role also supports team success by contributing investigative expertise, mentoring SIU Analyst I staff on quality fundamentals and escalating risk, trends and barriers to case progression.

Responsibilities

• Evaluate and develop leads, complaints, and/or investigations to determine if further investigation is warranted.
• Execute assigned investigations from start to closure (post-triage), including strategy, documentation and recommendations.
• Conduct interviews and outreach as required.
• Build defensible case narrative and prepare findings report with clear overpayment/impact logic (when applicable).
• Utilize data analysis techniques to detect aberrancies in health plan clients’ claims data and proactively seek out and develop leads/investigations.
• Review information contained in standard claims processing system files to determine provider billing patterns and detect potential fraudulent or abusive billing practices.
• Make potential fraud determinations by utilizing a variety of sources such as internal guidelines and Medicare and Medicaid regulations.
• Compile and maintain documentation and information related to investigations, cases, and/or leads.
• Participate in onsite audits in conjunction with investigation development.
• Develop and prepare potential Fraud Alerts and program vulnerabilities for submission to stakeholders.
• Prepare and submit external correspondence and reports, including overpayment letters and fraud case referrals.
• Prepare and submit correspondence to providers for medical record requests or suspension overpayment determinations.
• Serve as mentor/trainer to new CoventBridge Healthcare SIU staff.

Requirements

• Research and organization skills.
• Ability to establish and/or evaluate prioritization criteria.
• Time management skills and ability to meet deadlines.
• Verbal and written communication skills.
• Ability to work independently with minimal supervision.
• Ability to multi-task in a fast-paced environment.

Qualifications

• College or technical degree programs related to the position (e.g., Criminal Justice, Statistics, Data Analysis, etc.).
• Candidates with Accredited Health Care Fraud Investigator (AHFI) and Certified Fraud Examiner (CFE) Certifications will be given priority consideration.
• At least 1 year of experience in SIU, Program Integrity investigation/detection or a related field.

Benefits

• Medical, Dental, Vision plans.
• Life, LTD and STD paid by the employer.
• 401(k) with company match up to 4%.
• Paid Time Off and company paid holidays.
• Tuition assistance after 1 year of service.
• The salary range for this role is $74,000 to $87,000 annually.