Investigator

• Conduct comprehensive reviews of medical records and documents supporting claims for providers, suppliers, and pharmacies
• Provide investigative support to the Special Investigations Unit related to coding and billing issues
• Identify potential overpayments and suspected health care fraud and abuse
• Verify service authorizations and documentation against claim information
• Coordinate medical necessity and level-of-care determinations with Medical Directors
• Validate services against CMS and state-specific coverage, limitations, and exclusion guidelines
• Determine code appropriateness using administrative, medical, claim, and financial records
• Develop reports of findings and recommendations
• Communicate complex audit findings in meetings and judicial hearings
• Assist SIU investigators during interviews, discussions, and negotiations
• Perform retrospective and prepayment medical-record reviews
• Investigate provider billing patterns and determine payment based on records, claim history, codes, regulations, and policies
• Prepare findings summaries and recommend next steps for providers
• Identify preventative measures and recommend policy, procedure, and provider-practice changes
• Collaborate with investigators to identify fraud, waste, and abuse using clinical and coding expertise
• Perform other assigned duties and comply with policies and standards

Clinical Investigator reviewing behavioral health claims and detecting fraud for Centene’s healthcare members

Clinical Investigator, Behavioral Health

Clinical Investigator reviewing behavioral health claims and medical records for Centene, a national healthcare solutions provider. Identifying fraud, waste, abuse, overpayments, and billing irregularities for SIU investigations.

• Reviews and analyzes information gathered from databases to investigate alleged financial violations committed by a person or organization, including misuse of funds, misconduct, and corruption
• Prepares investigative reports, presents findings to senior management and relevant stakeholders, and supports control partners by recommending corrective actions to prevent future incidents and improve organizational practices
• Coordinates investigations by providing direction to multiple investigators, identifying issues and control weaknesses, sharing potential recommendations for courses of action, and testifying in court proceedings as needed

Senior Investigator leading financial crime investigations at Bank of America

Senior Investigator

Senior Investigator leading financial crime investigations in diversified operations at Bank of America. Gathering information on financial violations and coordinating investigative tasks.

• Conduct timely investigations including recorded statements and interviews of claimants, witnesses, and employers.
• Provide timely status updates to case manager and client.
• Timely and clear documentation of the claim files.
• Maintain highest level of confidentiality and professionalism.
• Develop appropriate investigative action plan.
• Ensure accuracy, quality and timeliness of the evidence gathered during an investigation as well as compliance with all applicable laws, legal codes, and governing agencies.
• Provide Claim Adjuster with timely investigation results and document investigative findings.
• Determine whether additional evidence is required including but not limited to accident reports, accident scene reconstructions, witness statements, police reports, expert opinion, etc.
• Provide recommendations and decisions surrounding investigative efforts.
• Perform detailed database queries on SIU investigations to include analysis and organization of critical data to assist during the assigned investigation.
• Be able to evaluate State compliance referrals, as applicable, when questionable or suspicious activity is identified.
• Maintain active membership in professional organizations that provide SIU assistance and resources.
• Establish and maintain relationships with law enforcement, government regulatory agencies and insurance industry personnel assisting when needed or required.

Investigating and identifying suspicious claims for an insurance investigative firm

SIU Investigator

Investigating and identifying suspicious claims for an insurance investigative firm in Phoenix, Arizona. Requires extensive experience in insurance claims, especially Workers’ Compensation.

• Independently handles complex identity theft cases, primarily related to credit cards
• Reviews and analyzes customer intake and case information
• Conducts in-depth investigations
• Determines appropriate case direction or resolution
• Works closely with investigators, caseworkers, and leadership to ensure cases are thoroughly developed, accurately documented, and ready to move forward
• Supports quality and consistency across the investigation process

Credit Card Identity Theft Investigator at U.S. Bank handling complex identity theft cases.

Credit Card ID Theft Investigator

Credit Card Identity Theft Investigator at U.S. Bank handling complex identity theft cases primarily related to credit cards. Collaborating closely with investigators and caseworkers to ensure quality and consistency in the investigation process.

Investigator jobs in Arizona

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Clinical Investigator, Behavioral Health

Senior Investigator

SIU Investigator

Credit Card ID Theft Investigator