Special Investigations Unit (SIU) Investigator
Company: nTech Solutions, Inc.
Location: Baltimore
Posted on: May 4, 2024
Job Description:
Terms of Employment
- Contract, 6 Months
- This position can either be 100% remote or hybrid - with
candidates working a few days onsite in the Baltimore, MD or Owings
Mills, MD office.
- Candidates interested in remote work must reside in the Eastern
Time Zone.
Overview Our client is seeking to hire six (6) Special
Investigations Unit (SIU) Investigators to join their team. The
role of the SIU Investigators 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
orchestrated by providers, members, brokers, or internal employees,
resulting in the savings and recovery of funds. The SIU
Investigators will be responsible for conducting preliminary
investigations into members that are suspected of committing fraud
when enrolling for health insurance. This will include researching
and analyzing member data and documentation, compiling this
research into a report, and ultimately generating templated letters
to send to the suspected violating members to attempt to determine
if fraud is occurring. General responsibilities include:
- 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.
- 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.
- Develop documentation to substantiate findings including formal
reports, spreadsheets, graphs, audit logs, use of anti-fraud
software and appropriately sourced reference materials.
- Ensure audits and investigations are timely, effective and
result in an overall achievement of unit goals.
- Researches and analyzes claims data using company anti-fraud
software, Excel, and other tools to proactively identify new
potential cases.
- 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.
- 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 synopsis, and
findings and to preserve as potentially discoverable
material.
Keywords: nTech Solutions, Inc., Montgomery Village , Special Investigations Unit (SIU) Investigator, Accounting, Auditing , Baltimore, Maryland
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