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.

• Support the university’s compliance with equal opportunity and civil rights policies
• Conduct neutral, thorough, and prompt investigations into complaints of discrimination
• Craft detailed investigative reports
• Provide a caring response to initial reports of discrimination
• Consult with other University offices in the resolution of complaints
• Serve on UWM's Title IX Working Group

Civil Rights/Title IX Investigator supporting compliance with equal opportunity laws

Civil Rights/Title IX Investigator

Civil Rights/Title IX Investigator conducting investigations and supporting compliance with equal opportunity laws at UWM. Position requires interpersonal skills and collaboration with various university offices.

• Conduct impartial and thorough investigations of employment-based complaints involving harassment, discrimination, failure to accommodate, or retaliation.
• Conduct interviews, gather records, draft reports, assist in decision making and appear in hearings, appeals and/or reviews as warranted.
• Work with Universities of Wisconsin Administration (UWSA) and Universities of Wisconsin (UWs) contacts to develop investigation techniques, guidelines, and report templates.
• Receive substantial and significant complaints of employment-based misconduct, harassment, discrimination, failure to accommodate, or retaliation from staff, students, or other members of the extended UW university communities as assigned.
• Identify UW university policies and/or State and Federal law provisions related to a complaint.
• Apply relevant policies and make findings of fact in individual cases.
• Provide regular updates to the Associate Vice President for Human Resources and UWSA leadership regarding case management approach, status, and progress.
• Maintain accurate, thorough, and confidential investigatory records and reports of finding.

Employment Investigator conducting investigations for Universities of Wisconsin

Employment Investigator

Employment Investigator responsible for conducting investigations of employment-based complaints at Universities of Wisconsin. Engaging with various stakeholders and ensuring compliance with policies and regulations.

• Responsible for the identification, investigation and development of cases against perpetrators of healthcare fraud
• Claim reviews for appropriate coding, data mining, entity review, law enforcement referral
• Responsible for identifying and developing enterprise-wide specific healthcare investigations
• Effectively establish rapport and on-going working relationship with law enforcement
• May assist in training of internal and external entities

Investigator II responsible for healthcare fraud investigation and claim reviews

Investigator II

Investigator II investigating healthcare fraud and conducting claim reviews across multiple health plans. Collaborating with law enforcement and assisting in policy development for preventive measures.

Investigator jobs in Wisconsin

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Clinical Investigator, Behavioral Health

Civil Rights/Title IX Investigator

Employment Investigator

Investigator II