SIU Investigator III, Health Plan Experience Required

CareSource

SIU Investigator III investigating healthcare fraud, waste, and abuse in health plans. Collaborating with teams for data analysis and managing high complexity investigations.

Posted 7/14/2026full-timeMissouri • 🇺🇸 United StatesMid-LevelSenior💰 $72,200 - $115,500 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in healthcare fraud investigations, utilizing strong analytical skills to identify trends and patterns in provider billing behavior. Proficient in medical coding and auditing, with a solid understanding of healthcare regulations and terminology.

Highest-signal resume keywords

Healthcare Fraud InvestigationsMedical CodingData AnalyticsAuditingMicrosoft Office Proficiency

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Data AnalysisMedical ResearchClaims ManagementCoding GuidelinesInterview TechniquesTrend IdentificationReport GenerationQuality AssuranceProvider Billing AnalysisHealthcare Regulations

Soft Skills

Problem SolvingCommunicationCollaborationAttention to DetailCritical Thinking

Tools & Technologies

Microsoft OutlookMicrosoft WordMicrosoft ExcelMicrosoft AccessMicrosoft PowerPoint

Industry Keywords

MedicaidMedicareCPT CodesHCPCS CodesICD CodesHealthcare RulesFraud, Waste, and Abuse (FWA)Medical BillingHealthcare ComplianceInsurance

About the role

Key responsibilities & impact

Responsible for investigating and resolving high complexity allegations of healthcare fraud, waste and abuse (FWA) by medical professionals, facilities, and members
Research, gather, and analyze data to identify trends, patterns, aberrancies, and outliers in provider billing behavior
Serve as a subject matter expert for other investigators
Develop, coordinate and conduct strategic fact-driven investigative projects
Manage the development, production, and validation of reports generated from detailed claims, eligibility, pharmacy, and clinical data
Ensure quality outcomes for investigative team through auditing and oversight
Use knowledge of coding guidelines to analyze complex provider claim submissions
Prepare and conduct in-depth complex interviews relevant to investigative plan

Requirements

What you’ll need

Bachelor’s Degree or equivalent years of relevant work experience in Health-Related Field, Law Enforcement, or Insurance required
Minimum of five (5) years of experience in healthcare fraud investigations, medical coding, pharmacy, medical research, auditing, data analytics or related field is required
Intermediate proficiency level in Microsoft Office to include Outlook, Word, Excel, Access, and PowerPoint
Knowledge of Medicaid, Medicare, healthcare rules preferred
Background in medical terminology, CPT, HCPCS, ICD codes or medical billing preferred

Benefits

Comp & perks

bonuses tied to company and individual performance
substantial and comprehensive total rewards package