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Position Summary
 

The SIU Investigator looks into suspected fraud, waste and abuse (FWA) by providers, suppliers, members, and other entities. The work covers both of Martin’s Point’s health plans: Generations Advantage and the US Family Health Plan (TRICARE). The SIU Investigator reports to the Director, Special Investigations Unit (SIU), and manages a caseload from intake through resolution. That includes data analysis, medical record review, interviews, overpayment recovery, and referrals to federal oversight entities and law enforcement. As one of the first members of a newly established SIU, the Investigator will help shape investigative standards, procedures, and cross-functional workflows.

Job Description

PRIMARY DUTIES AND RESPONSIBILITIES

• Investigates suspected FWA from start to finish. Referrals come from the compliance hotline, internal departments (Claims, Compliance, Payment Integrity, Medical Economics, Utilization/Quality Management, Network, Data & Analytics, and external sources) For each case, develops a plan that defines the allegation, scope and estimated financial exposure.
• Analyzes claims data to identify billing patterns that stand out from peers, to estimate overpayment exposure, and to support statistically valid sampling and extrapolation, if deemed appropriate.
• Reviews medical records and supporting documentation against:
  • CMS and TRICARE requirements
  • Martin’s Point payment policies
  • CPT, HCPCS, and ICD-10-CM coding guidelines
  • Applicable National and Local Coverage Determinations
  • Coordinates clinical and coding review as needed with other internal departments.
• Conducts member and provider outreach, including investigative interviews
• Keeps thorough, well-documented case files. Drafts findings letters and overpayment determinations, and recommends corrective actions such as provider education, prepayment review, recoupment, and network action.
• Prepares referrals to the CMS Investigations MEDIC (the contractor that handles the Medicare Advantage FWA referrals), the Defense Health Agency Program Integrity Office, HHS-OIG, and law enforcement within required timeframes. Responds to those entities requests for information.
• Keeps case management records accurate and contributes to SIU reporting, including recoveries, cost avoidance, and referrals, using NHCAA-aligned measures.
• Tracks emerging fraud schemes and develops to recommend and assist in developing new analytics and edits.
• Supports the organization’s FWA compliance obligations under the Medicare Advantage and USFHP contracts, including contributing to FWA training content.

Employees are expected to work consistently to demonstrate the mission, vision, and core values of the organization.

POSITION QUALIFICATIONS

Education:

• Bachelor’s degree in criminal justice, health care administration, accounting, or other related field, or an equivalent combination of education and experience.

 

Licensure/certification:

•  At least one of the following certifications preferred: AHFI, CFE, CPC, CCS, or CPMA.

Experience:

• Five or more years in health care fraud investigation, SIU, payment integrity, program integrity, or law enforcement health care fraud work required.
• Medicare Advantage experience required. TRICARE or other government program experience preferred.

Knowledge:

• Demonstrates an understanding of and alignment with Martin’s Point Values.
• Working knowledge of Medicare Advantage program integrity requirements, the False Claims Act, the Anti-Kickback Statute, the Stark Law, and overpayment reporting obligations.

 

Skills:

• Strong command of CMS-1500 and UB-04 claim formats and coding conventions.
• Investigative writing that can withstand legal and regulatory scrutiny.
• Skilled interviewer with sound judgment, discretion, and rigorous handling of protected health information (PHI).
• Advanced Excel skills, SQL, PowerBI, or similar tools strongly preferred.

Abilities:

• Able to work independently and contribute in a start-up environment where procedures are still being built as we grow our SIU department internally.

Pay Range: $75,584.55 - $93,369.15 To promote pay equity, Martin’s Point Healthcare has established defined salary ranges for each role. Compensation is established within the posted range based on a variety of factors, including relevant years of experience, current market conditions, internal equity, and budget considerations. The pay range reflects the potential compensation for this role based on a full-time position. Employees may also be eligible for additional compensation, such as incentive or commission-based programs, where applicable and subject to the terms of the applicable plan. Final compensation is determined at the conclusion of the interview process. We encourage you to apply even if your desired compensation falls outside of the listed range. In addition to base compensation, we offer a comprehensive benefits package including medical, dental, vision, retirement savings with employer contributions, paid time off (including volunteer time off!), pie day, and other employee benefits.

This position is not eligible for immigration sponsorship.

We are an equal opportunity/affirmative action employer.

Martin's Point complies with federal and state disability laws and makes reasonable accommodations for applicants and employees with disabilities. If a reasonable accommodation is needed to participate in the job application or interview process, to perform essential job functions, and/or to receive other benefits and privileges of employment, please contact jobinquiries@martinspoint.org

Do you have a question about careers at Martin’s Point Health Care? Contact us at: jobinquiries@martinspoint.org