Special Investigative Unit Investigator

SGS_JOB_3116

Business Support
Remote
FACETs
Microsoft Power BI
RATSTATS
presentation skills

Contract - 3 months

Special Investigative Unit (SIU) Investigator responsible for investigating reports of non- compliance with corporate and regulatory policies, including reports of fraud, waste, or abuse. As a member of the SIU team, the investigator recommends methodologies which help prevent improper conduct by identifying, assessing, and correcting areas of noncompliance in risk areas in an effective manner. Utilize monitoring systems to track, remediate and create reports particularly from the data mining tool. Be responsible for all assigned investigations, follow-ups, and resolutions. Possess the judgement and discretion to handle cases that are sensitive and/or high profile, and the intellectual rigor and professional experience to work on complex cases that can be national in scope and involve intricate health care fraud schemes.

Job Responsibilities:

  • Independently analyze public and HAP internal data and information to develop preliminary assessment of facts to determine if full investigation is warranted. Develop investigative strategy and approach to complete investigation.
  •  Assembles evidence and documentation to support successful adjudication, where appropriate.
  •  Conducts on-site audits of provider records ensuring appropriateness of billing practices.
  •  Conduct interviews with providers, employees, members, and witnesses as part of the investigative process.
  •  Prepares complex investigative and audit reports with the ability to present investigation summaries that include metrics, trends, and schemes to various stakeholders, including enforcement agencies.
  •  Must be able to craft a well organized referral explaining the alleged fraud in a fraud referral to regulators.
  •  Coordinates investigation with law enforcement authorities and regulatory agencies.
  •  Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas.
  •  Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed.
  •  Follows established guidelines/procedures.
  • Censure that the compliance department meets the required OIG effective compliance program elements by promptly responding to identified issues and concerns within the organization.
  •  Work independently and manage a caseload which include investigations, identifying schemes, tracking, trending, and reporting instances of non-compliance.
  •  Respond to alleged violations of rules, regulations, policies, procedures, and Code of Conduct by evaluating or recommending the initiation of investigative procedures. Ensure policies and procedures are followed for the general operation of the compliance program and its related activities to prevent illegal, unethical, or improper conduct.
  •  Independently move an investigation to the next step in the investigative process with minimal assistance and errors. This includes from the opening to final disposition.
  •  Independently develop new cases based on proactive data mining efforts.
  •  Respond to a complaint, take statements, document effectively and identify any fraud, waste or abuse.   
  •  Identify patterns and trends to generate new investigative leads.
  •  Collaborative Skills: Demonstrates strong teamwork and collaboration abilities, effectively working with other investigators to achieve common goals and take responsibility for team outcomes while contributing to the overall success of the team.
  • Adaptability: Shows flexibility in adapting to different roles and responsibilities within the team, contributing to various aspects of investigations as needed.
  • Demonstrated experience with Managed Care products such as Medicare, Medicaid, ACA, and commercial insurance. 
  •  Develop and facilitate training regarding Fraud Waste and Abuse requirements, HFH Non-retaliation policy, Code of Conduct, and government program requirements.
  • Perform other related duties as assigned.

Skills:

  • Experience working with RATSTATS or similar programs for sampling and extrapolation.
  • Proficiency using excel including ability to analyze large data sets to identify trends, anomalies, and opportunities for improvement, using data visualization techniques to present findings effectively
  • Ability to use excel or other Microsoft software to automate repetitive processes and enhance existing workflows through advanced Excel features, including macros, pivot tables, complex formulas and power query
  • Experience with Microsoft Power BI and knowledge of sequel preferred.
  • Excellent verbal, written and presentation skills
  • Ability to work with individuals of diverse backgrounds at various levels
  • Objective and creative analytical and auditing skills
  • Knowledge of various product lines in health care industry
  • ·Strong organizational, interpersonal, and communication skills
  • Inquisitive nature with ability to analyze data to metrics
  • Knowledge of healthcare payment methodologies
  • Knowledge and experience with FACETs or similar claim systems.
  • Strong personal and professional ethics

Education/Experience:

  • Bachelors Degree (Masters or Law degree preferred), CFE or AHFI certification, Minimum of 3 years experience in healthcare, pharmacy technician, claims adjudication, medical billing/coding, nursing or law enforcement, Previous experience working for a health insurance payer, Minimum of 2 years experience conducting comprehensive investigations preferably with interaction with state, federal and local law enforcement agencies, Previous experience with FACETs system

Related Jobs

Healthcare Consultant I - SW Ohio

Business Support
 Ohio
03+ Months Extendable

Candidates must reside in one of these counties: Central/Southeast OHIO Counties ** Candidates could be required to travel to the corporate office in Franklin County for onsite meetings. These usually happen 1-2 times a year. ** Travel to office is not reimbursable.

Bilingual
Spanish
Healthcare consultant
Case Management
Case Manager
Case Management Coordinator

Healthcare Consultant I - SW Ohio

Business Support
 Ohio
03+ Months Extendable

Location (mandatory): SW OHIO Counties: Adams, Allen, Auglaize, Brown, Butler, Champaign, Clark, Clermont, Clinton, Darke, Defiance, Fulton, Green, Hamilton, Hardin, Henry, Lawrence, Logan, Lucas, Madison, Mercer, Miami, Montgomery, Paulding, Preble, Putnam, Scioto, Shelby, Van Wert, Warren, Williams in OHIO ): Candidates must reside in one of these counties: SW OHIO Counties: Adams, Allen, Auglaize, Brown, Butler, Champaign, Clark, Clermont, Clinton, Darke, Defiance, Fulton, Green, Hamilton, Hardin, Henry, Lawrence, Logan, Lucas, Madison, Mercer, Miami, Montgomery, Paulding, Preble, Putnam, Scioto, Shelby, Van Wert, Warren, Williams ** Candidates could be required to travel to the corporate office in Franklin County for onsite meetings. These usually happen 1-2 times a year. **

Bilingual
Spanish
Healthcare consultant
Case Management
Case Manager
Case Management Coordinator

Healthcare Consultant I - North Miami area

Business Support
 Florida
03+ Months Extendable

Location (mandatory): Candidates MUST reside in North Miami, Aventura, Hialeah or Miramar in Florida Candidates must reside in North Miami, Aventura, Hialeah or Miramar. Training will be conducted remotely via Microsoft Teams. Candidates will travel approximately 75% of the time within the region seeing members at home, in assisted living facilities and nursing homes

Bilingual
Spanish
Healthcare consultant
Case Management
Case Manager
Case Management Coordinator

Healthcare Consultant I: Field Case Management POLK County

Business Support
 Florida
03+ Months Extendable

Location (mandatory): Lakeland, Auburndale, Bartow, Lake Wales, Winter Haven in Florida Work from Home. must be in one of these cities: Lakeland, Auburndale, Bartow, Lake Wales, Winter Haven Bilingual (Spanish) seeking self-motivated, energetic, detail oriented, highly organized, tech-savvy Case Management Coordinator to join our Case Management team in the Lakeland, Auburndale, Bartow, Lake Wales, Winter Haven in Florida

Bilingual
Spanish
Healthcare consultant
Case Management
Case Manager
Case Management Coordinator

Healthcare Consultant I - Miami-Dade County, FL (Hialeah)

Business Support
 Florida
03+ Months Extendable

Location (mandatory): Hialeah/ Miami-Dade County, FL This role will require 50-75% travel for face-to-face visits with members in the Hialeah (Must be in 33010, 33012, 33013, 33014, 33015, 33016, 33018) area of Miami-Dade County, FL.

Bilingual
Spanish
Healthcare consultant
Case Management
Case Manager
Case Management Coordinator

Paralegal

Business Support
 Arizona
06+ Months Extendable

Location (mandatory): Phoenix, AZ 85040 (Hybrid) The person in this role is responsible for providing Paralegal support with Medicaid state fair hearings to ensure compliance with federal and state standards.

Paralegal
Medicaid
Federal
STATE
Medicare
Litigation
Paralegal Certification
Attorney

Illustrator II

Business Support
Remote
6 months Contract

ad-hoc work - when manager reaches out. Hours will vary must be ok viewing sensitive photos will be working across many divisions on presentations for current medical professionals Please submit portfolio and resume together Medical/scientific drawings no defined work schedule. manager ok with someone working a full time job and this role on the side

Medical/scientific
technical
medical
architectural
scientific and cartoon illustrations

Video Surveillance Operator

Business Support
 Nevada
6 Months

Location (mandatory): Las Vegas, NV The Surveillance Operator is a desk-based, onsite security monitoring role responsible for reviewing live video feeds, identifying potential threats, and taking immediate action such as issuing real-time audio warnings or contacting law enforcement/property representatives. Operators monitor multiple sites nationwide using proprietary software and work in a fast-paced, multi-screen environment. This role is not related to casino surveillance and is not located on the Las Vegas Strip. WORK ENVIRONMENT: Fast-paced operations center Heavy computer and multi-monitor use Safe, climate-controlled office setting Structured, non-flexible schedules — employees must work the shift hired for Communication currently via Microsoft platforms; transitioning to Google Meet/Google Mail

CCTV
Video Surveillance
Investigation

Physician Assistant

Business Support
 Texas
06+ Months Extendable

Location (mandatory): San Antonio, TX 78258 Physician Assistants will work in collaboration with a dedicated clinical care team to provide evidenced-based care to a panel of patients. The clinical care team will work with the provider daily to drive better outcomes for entire panel of patients. This will include accurate assessment, diagnosis, treatment, management of health problems, health counseling, and disposition planning.

Physician
Physician Assistant
Primary Care
Chronic
logo

At SGS Consulting, we go beyond resume-job matches, creating meaningful connections and pathways for individuals to thrive in defining careers.


© 2026 All rights reserved.
logologologologo