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Position:

SIU Investigator

Position Summary:

The Special Investigations Unit (SIU) Investigator assists the Manager in the implementation and daily operation of the organization’s SIU Program and all related activities for the Company’s Medicare Advantage and Prescription Drug health plan programs and its clients. The Investigator works both independently and collaboratively with others to investigate and resolve allegations of non-compliance, and to discover, investigate, and prevent fraud, waste and abuse. The Investigator also works in conjunction with subject matter experts on the Compliance Team to identify root causes of non-compliance and appropriate corrective actions.

Job Description:

Role and Responsibilities

• Conduct investigations into allegations of non-compliance, including marketing and sales complaints, and fraud, waste and abuse. Research, gather information and evidence, conduct timely and thorough interviews with internal and external individuals at all levels, disseminate information, resolve issues, and document information relative to each incident.
• Work with departments and subject matter experts to identify potential incidents of non-compliance and appropriate corrective actions.
• Prepare written incident reports for management review, to include incident details, status, resolution, root cause, and other pertinent information. Assist the Manager in preparing SIU activity monitoring reports for management and various workgroups and Committees.
• Present status and findings in weekly internal and client meetings for discussion and decision-making.
• Recognize urgent and sensitive issues/incidents and escalate to management in a timely manner to facilitate appropriate and timely response.
• Routinely monitor regulatory and hotline incidents management systems for new incidents/inquiries. Respond timely and maintain accurate and thorough documentation in incidents systems. Adhere to established timeframes for completion and closure of incidents.
• Conduct marketing and sales surveillance to ensure compliance with Medicare Marketing Guidelines and internal policies and procedures.
• Conduct research of laws, regulations, guidelines, contracts, and policies and procedures to understand the operational and compliance requirements of the Company and its clients.
• Maintain education, awareness, and knowledge of current regulations and best practices in the health care industry, and specifically in investigations techniques and reporting.
• Assist in the development, review, and update of policies and procedures that meet regulatory and departmental requirements.
• Build and maintain good rapport and work effectively with individuals in all areas of the Company.
• Assist as needed in staff education relative to SIU and compliance investigations, including creating presentations or other materials for training purposes as directed.
• Participate in compliance communication, awareness, education, and training activities as needed to support the Compliance and SIU Programs.
• Assist in preparing for internal and regulatory audits, including the collection, preparation, and submission of SIU information, data, and documents to regulators and auditors.
• Participate in various team and committee meetings; actively contribute and take a leadership role to satisfactorily complete the group’s objectives.
• Communicate the status of assignments and projects to Manager, internal individuals and teams, and internal and external clients.
• Proactively identify areas of improvement for self and the department, and participate in the development and completion of individual and departmental objectives and performance improvement initiatives.
• Other related duties as assigned to meet departmental and Company objectives.

Experience, Qualifications, and Education

• Bachelor’s degree in business, health care administration, or related field, or in lieu of a degree, two additional years of relevant experience
• One to three years of experience in investigations, compliance, or healthcare operations
• Experience in a federally regulated environment, including Medicare Advantage, Medicaid, and/or managed care program experience, considered a plus
• Proven investigatory skill; ability to organize, analyze, and effectively determine risk and appropriate response; ability to remain objective and separate facts from opinions
• Excellent oral and written communication skills; effective interpersonal skills and customer service focus; ability to interact with individuals at all levels and personalities
• Strong logical, analytical, critical thinking, and problem-solving skills
• Familiarity with healthcare laws, regulations, and standards; proven ability to research and interpret regulatory requirements
• Understanding of health plan operations, including customer service, claims processing, medical management, enrollment, and sales & marketing
• Initiative, excellent follow-through, persistence in locating and securing needed information
• Detail-oriented, self-motivated, able to meet tight deadlines
• Fundamental understanding of audits and corrective actions
• Ability to multi-task and operate effectively across geographic and functional boundaries
• Ability to develop realistic goals and objectives, track progress, and adapt to changing priorities
• Energetic and forward thinking with high ethical and professional standards
• Collaborative and team-oriented; ability to work effectively in an open office environment

Lumeris is an EEO/AA employer M/F/V/D.

Location:

St. Louis, MO

Time Type:

Full time