Special Investigations Unit Program Manager
Peak Health
full-time
Posted on:
Location Type: Remote
Location: Remote • 🇺🇸 United States
Visit company websiteJob Level
Mid-LevelSenior
About the role
- Develop, maintain, and execute annual audit program
- Ownership of the SIU referral intake and triage process
- Perform investigations into suspected fraud, waste, and abuse
- Leads process and reporting to ensure proper notification of FWA activity
- Identify opportunities for improvement through audit process
- Creation and maintenance of departmental policies and procedures
- Work collaboratively with other departments to educate providers and vendors
- Track, report, and follow-up on overpayments and recoveries
- Collaborate with Compliance, Legal, Claims, and accounting departments
- Serve as a subject matter expert on FWA prevention and detection
Requirements
- Bachelor's degree or equivalent
- Four (4) years of experience as a managed care insurer focusing directly on payment integrity and special investigations
- Certified Fraud Examiner (CFE) preferred
- Accredited Health Care Fraud Investigator (AHFI) preferred
- Certified Professional Coder (CPC) preferred
- Knowledge of Medicare, Medicaid and Commercial Coding rules and regulations
- Medical chart review/auditing expertise
Benefits
- Health insurance
- Paid time off
- Professional development
- Remote work options
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard skills
audit program developmentfraud investigationoverpayment trackingmedical chart reviewpolicy creationreportingpayment integrityspecial investigationsFWA detectionFWA prevention
Soft skills
collaborationcommunicationleadershipproblem-solvingorganizational skills
Certifications
Certified Fraud Examiner (CFE)Accredited Health Care Fraud Investigator (AHFI)Certified Professional Coder (CPC)