Conducts investigations and research relating to preventing, detecting and correcting fraud, waste and abuse in all lines of business. Maintains a caseload and performs activities relating to intake, triage, planning, conducting, reporting and closing of complex investigations.

• Maintains an investigative caseload consisting of mid to high level complexity and performs a full range of investigative functions from case development to case closing.
• Ensures investigative and other activities—such as intake, planning, research, analysis, record reviews, interviews, coordination, reports, referrals and closing—are thorough and timely and performed in accordance with established procedures and practices.
• Performs data mining, analysis and research to identify potential opportunities to investigate suspected FWA.
• Identifies relevant information during the referral intake and triage process. Responds to requests for information and enhances the progress of assigned cases and other FWA projects.
• Communicates updates on cases and other projects to supervisors, managers, and other the Health Plan departments and committees.
• Prepares, coordinates and assists with the development and delivery of complex written documents and oral briefings and presentations on SIU cases, operations and other activities.
• Ensures entries in information technology systems are timely, accurate and consistent with established procedures and practices.
• Provides technical guidance, training and mentoring to other team members on a full range of investigative functions and operations.
• Proposes and assists with the development and implementation of initiatives—and the completion of regulatory planning and reporting requirements—in collaboration with leadership, other departments, and external entities as appropriate.
• Represents SIU supervisors and managers in communications and meetings with external partners, regulators and vendors.
• Supports legal proceedings as necessary, including law enforcement subpoenas, data requests, and preparation for civil or criminal actions.

Work is typically performed in an office environment. Travel may be required. Accountable for satisfying all job specific obligations and complying with all organization policies and procedures. The specific statements in this profile are not intended to be all-inclusive. They represent typical elements considered necessary to successfully perform the job. 

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*Relevant experience may be a combination of related work experience and degree obtained (Associate’s Degree = 2 years; Bachelor’s Degree = 4 years).

If a suitably experienced candidate cannot be found, applicants who meet the basic qualifications but possess fewer years of experience will be considered for hire at a lower level. Salary would commensurate with experience.