Special Investigation Unit – Investigator
Employee
–
06/11/24
SIU Investigator
Location: USA-
Job Description:
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Position Summary:
Responsible for assisting in the implementation and daily operation of the organization’s Special Investigations Unit (SIU) Program and all related activities for the Company’s Medicare Advantage and Prescription Drug health plan programs and its clients. Collaborates to investigate and resolve allegations of non-compliance, and to discover, investigate, and prevent fraud, waste, and abuse. Also works in conjunction with subject matter experts on the Compliance Team to identify root causes of non-compliance and appropriate corrective actions.
Job Description:
Primary Responsibilities
Conducts investigations into allegations of non-compliance, including marketing/sales and fraud, waste, and abuse. Researches, gathers information and evidence, and conducts timely and thorough interviews with team members at all levels. Disseminates information, resolves issues, and documents information relative to each incident.
Works cross-functionally to identify potential incidents of non-compliance and appropriate corrective actions.
Prepares written incident reports for review, to include incident details, status, resolution, root cause, and other pertinent information. Assists in preparing SIU activity monitoring reports.
Presents status and findings in weekly internal and client meetings for discussion and direction.
Identifies urgent and sensitive issues/incidents and escalates to facilitate appropriate and timely response.
Monitors regulatory and hotline incident management systems for new incidents/inquiries. Responds timely and maintains accurate and thorough documentation in incidents systems. Adheres to established timeframes for completion and closure of incidents.
Conducts marketing and sales surveillance to ensure compliance with Medicare Marketing Guidelines and internal policies and procedures.
Maintains education, awareness, and knowledge of current regulations and best practices in the health care industry, specifically in investigation techniques and reporting.
Assists in review and update of policies and procedures that meet regulatory and departmental requirements.
Fosters and maintains good rapport with team members in all areas of the Company.
Participates in team member education relative to SIU and compliance investigations, including creating presentations or other materials.
Participates in compliance communication, awareness, education, and training activities to support the Compliance and SIU Programs.
Assists in preparing for internal and regulatory audits, including the collection, preparation, and submission of SIU information, data, and documents to regulators and auditors.
Participates in various team and committee meetings.
Communicates the status of assignments/ projects at all levels, internally and externally.
Other related duties as assigned.
Qualifications
Bachelor’s degree in related field (i.e. Mathematics, Business, Health Information Administration, Statistics) or equivalent
3+ years of experience in investigations, compliance, healthcare operations, or the knowledge, skills, or abilities to succeed in the role
Solid investigatory, critical thinking, and problem-solving skills
Ability to organize, review, and effectively identify risk and appropriate response
Firm interpersonal, collaboration, customer service, and oral/written communication skills with the ability to interact with team members at all levels
Familiarity with healthcare laws, regulations, and standards
Ability to research and interpret regulatory requirements
Working knowledge of health plan operations, including customer service, claims processing, medical management, enrollment, and sales & marketing
Skilled at meeting tight deadlines, being self-motivated and detail-oriented
Good understanding of audits and corrective actions
Ability to multi-task and operate effectively cross-functionally at all levels
Ability to develop realistic goals, track progress, and adapt to changing priorities
Capable of operating with high ethical and professional standards
Preferred:
Experienced in a federally regulated environment, including Medicare Advantage, Medicaid, and/or managed care program experience
Working Conditions
While performing the duties of this job, the employee works in normal office working conditions.
Disclaimer
The job description describes the general nature and level of work being performed by people assigned to this job and is not intended to be an exhaustive list of all responsibilities, duties and skills required. The physical activities, demands and working conditions represent those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential job duties and responsibilities.
#LI-REMOTE
Lumeris is an EEO/AA employer M/F/V/D.
The hiring range for this position is:
$49,200.00-$63,000.00
Factors that may be used to determine your actual pay rate include your specific skills, experience, qualifications, location, and comparison to other employees already in this role. This role may also be eligible for incentive compensation. At Lumeris, we are committed to providing a total rewards package that supports your overall well-being. Our benefits include medical, vision, dental, well-being programs, 401(k) with company matching, life insurance, paid time off including paid leave, and so much more. Learn more by visiting our Careers Page.
Member Facing Position: No- Not Member or Patient Facing Position
Location:Remote, USA
Time Type: Full time
Lumeris and its partners are committed to protecting our high-risk members & prospects when conducting business in-person. All personnel who interact with at-risk members or prospects are required to have completed, at a minimum, the initial series of an approved COVID-19 vaccine. If this role has been identified as member-facing, proof of vaccination will be required as a condition of employment.