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

Project Scheduler – Nuclear Projects

Business Support
 Washington
12 Months

Location : Richland, WA 99354. The Project Scheduler for Nuclear Projects in Richland, WA, will be responsible for scheduling activities, ensuring schedule integrity, and supporting project managers with developing and maintaining schedules for online and outage nuclear projects. The position requires proficiency in Primavera scheduling tools and experience with project management in the nuclear power industry. The role involves collaborating with various teams to create, update, and maintain project schedules, ensuring compliance with technical specifications, maintenance rules, and industry best practices.

Schedule
P6

Demand Planner II

Business Support
 Colorado
12 months Contract with possible extension

Location : Colorado Springs, CO 80915 Shift Hours: 7am-3:30pm On Site PPE- safety glasses and safety toe shoes Interviews will be via teams, maybe in person

SAP
ERP System
Microsoft Excel and Outlook

Demand Planner I

Business Support
 Colorado
12 months Contract with possible extension

Location : Colorado Springs, CO 80915 Shift Hours: 7am-3:30pm On Site PPE- safety glasses and safety toe shoes Interviews will be via teams, maybe in person

SAP
ERP System
Microsoft Excel and Outlook

Construction Manager I

Business Support
 Illinois
12 Months

Location : Byron Illinois Experienced Construction Manager / Construction Supervisor needed to support major transmission and substation projects at the Byron, IL site. This role involves overseeing the construction of an electric switchyard within a substation environment, providing field supervision, and ensuring safe, efficient execution of EPC construction activities. The ideal candidate has strong commercial construction experience, hands-on knowledge of electric equipment installation, and experience with transmission and distribution systems. Prior experience at the Byron station and familiarity with nuclear environments is preferred.

Construction
Transmission.

People Connect Associate

Business Support
 New York
$30 on w2 on w2
6 Months (possible extension)

Location (mandatory): New York, NY 10036 This role reports to the Global People Team Lead, based in London, and works closely with People team colleagues across the Americas, EMEA and APAC. The People Connect Associate delivers high-quality, timely advice and support to employees and managers. You’ll collaborate with teams across People Operations, Business Partners and Centres of Excellence to provide seamless support and drive process improvements. You’ll offer practical guidance, resolve complex queries and help enhance our core people platforms, ServiceNow and Workday, enabling smarter self-service and continuous improvement throughout the employee lifecycle. • Client is expanding its commercial footprint internationally, and to support this exciting phase of growth we’re looking to hire a People Connect Associate in New York. With experience in building strong relationships with employees and managers, you’ll deliver an excellent employee experience across the full lifecycle. You’ll wear multiple hats where needed, coordinating with COEs and Business Partners on a variety of topics such as global mobility, compensation alignment, and organizational transformation and redesign projects. We work as part of the wider People team, partnering across regions to deliver support that’s simple, efficient, and human — using digital tools and expert guidance to make every interaction easier. To be successful, you’ll thrive on collaboration, think critically to solve problems, and live our values of Collaboration, Trust, Impact, and Excellence in everything you do.

Workday
ServiceNow
HR advisory
US employment law

Piping Material Engineer

Business Support
 Texas
03 Months + (Possibilities of Extension)

Location (mandatory): Houston, TX 77001 (On-site) The Piping Material Engineer will support large industrial and construction projects by leading material selection, analyzing materials, developing conceptual designs, and ensuring compliance with engineering standards. The role provides technical support, resolves complex materials issues, and coordinates with multidisciplinary teams while working on advanced manufacturing and technology-focused facilities.

Piping Material Engineering
Smart Plant Reference Data (SRD)
ASME/API/AWWA/ASTM/MSS Codes
BIM Piping FabParts
Material Selection
Corrosion Engineering
Welding & Materials Analysis

Manager Retail Development

Business Support
 California
$63 - $73/HR on W2
06 months

Location: El Segundo, CA (Hybrid) Seeking a professional and detail-oriented Manager, Retail Development, to support Mattel’s Consumer Products (CP) organization based at our global headquarters in El Segundo, CA. This individual will be responsible for pitching, developing and executing consumer products programs at top U.S. retail accounts. This role manages relationships with external retail buyers and works cross-functionally with internal partners across Franchise, CP Creative, Sales, Retail Marketing and Brand Marketing to drive company growth of CP and cross-category programs at retail.

Retail Development
Franchise Development
and Consumer Products.

Patient Financial Representative Senior

Business Support
 Texas
3 months + (Possibilities of Contract Extension)

Location : San Antonio, TX, 78229 Responsible for resolving and reconciling patient account balances within the Revenue Cycle department. Handles collections, cash reconciliation, and billing functions for inpatient and outpatient accounts using UB-04 and HCFA 1500 forms. Ensures accurate claims processing, payor follow-up, and compliance with coding and regulatory guidelines. Provides effective communication and support to internal/external customers to meet performance, quality, and productivity standards.

Hospital Billing (UB-04/HCFA 1500)
Cash Reconciliation
Account Resolution Abilities

CAD Facilities Drafter

Business Support
 Pennsylvania
9 Months

Location : Philadelphia PA 19103 The CAD Facilities Drafter will support mapping and engineering teams by updating and maintaining electric and gas facility maps using Microstation, G/Tech, and related CAD tools. This role focuses on ensuring accuracy of utility infrastructure drawings, validating as-built information, and managing construction standard documentation. The Drafter will also research and verify engineering changes using Asset Suite 8 and contribute to backlog mapping projects. Candidates must have strong CAD drafting abilities, experience with utility maps, and the ability to interpret construction standards.

CAD
MicroStation
logo

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


2025. All right reserved.
logologologologo