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

Hospital Healthcare Systems Business - Sales

Business Support
 Texas
8 months Contract (Possibility of extension)

The Healthcare Systems Business Specialist has multiple responsibilities around the promotion of products and resources to a variety of stakeholders within Healthcare Systems and Hospitals, such as Doctors, Nurses, Pharmacists, Hospital Administrators, Discharge Planners, and Buyers. Educating customers on characteristics, indicated treatments related to assigned promoted products. Professionally represent in the field and/or virtually to ensure high levels of visibility and customer satisfaction. The Hospital / Healthcare Systems Business Specialist plays an important role in establishing effective communications and relationships with key external and internal customers within Healthcare Systems.

Strategic Key Account Plans
providing account strategies
Customer support

Instructional Designer & Learning Specialist

Business Support
 Massachusetts
50.00
05 Months Contract + (Highest possibilities of contract extension)

Location (mandatory): Cambridge, MA 02140 (Hybrid) Role: Instructional Designer & Learning Specialist focused on harmonizing and standardizing existing BO training materials, transforming presentation content into engaging and interactive learning experiences, introducing assessments and feedback mechanisms, and helping define a scalable training framework.

Training Development
Instructional Design
E-Learning Development
LMS Platforms
Articulate 360
Adobe Captivate
iSpring
Camtasia
Content Harmonization
Curriculum Development
Adult Learning Principles
Interactive Learning Design
Assessments & Quizzes
Training Framework Development
Presentation Skills

Clinical Trial coordinator

Business Support
 Arizona
$35.00
12 months Contract (Possibility of extension)

This is a requisition for several Clinical Science Program Specialists in CDx Pharma Services.

Strong communication
organizational skills

Senior Implementation Manager

Business Support
 Washington
$127/hr on W2
12 Months

Location : Richland, WA The Senior Implementation Manager provides technical expertise, governance, oversight, and project support for high-risk enterprise projects within a nuclear power generation environment. This role partners with Project Managers to ensure project execution is safe, efficient, cost-effective, and completed on schedule. The ideal candidate will possess extensive experience in nuclear plant operations, outage management, maintenance execution, regulatory compliance, and project implementation strategies. This position serves as a subject matter expert responsible for improving project quality, reducing risks, and enhancing execution performance.

Nuclear Power Plant Operations
Refueling Outages
Primavera P6
Microsoft Project
Enterprise Asset Management Systems
ASME Section XI
Risk Management
Project Oversight
Maintenance & Engineering Processes
Regulatory Compliance

Technical SEO Product Manager

Business Support
 Texas
05 Months

Location : Fort Worth, TX (Hybrid) The Technical SEO Product Manager is responsible for driving technical SEO initiatives, analyzing organic search performance, and delivering actionable insights to improve website visibility and engagement. This role serves as a bridge between business stakeholders, SEO consultants, and engineering teams, ensuring successful implementation of SEO enhancements across a complex multi-language web ecosystem. The ideal candidate will have strong experience in SEO analytics, web performance reporting, and enterprise-level digital environments.

Technical SEO
Adobe Analytics
Google Analytics
Google Search Console
AIO/GEO Strategies
Product Management

Web Producer (MC Production)

Business Support
 California
$39.00 - $49.00
06 Months

Location : El Segundo, CA The Producer (MC Production) is responsible for leading ecommerce content production and website operations while supporting product launches and digital experiences. This role requires strong project management, people leadership, and content management expertise, with a focus on Shopify-based ecommerce platforms. The ideal candidate will have experience in DTC/ecommerce environments, website content management, and leading production teams to deliver high-quality site experiences.

Shopify
Ecommerce
People Management
Content Management
Project Management
HTML

Payroll Specialist

Business Support
 Florida
3 Months

Location : Remote (FL) The Payroll Specialist is responsible for managing Tier 2 payroll cases, investigating complex payroll issues, and ensuring timely resolution through collaboration with HR, Finance, and IT teams. This role requires strong payroll expertise, analytical problem-solving skills, and experience with payroll systems and compliance regulations. The ideal candidate will be customer-focused, detail-oriented, and capable of managing multiple cases while driving process improvements.

Payroll Processing
Case Management
SAP ECP
Excel
Payroll Tax Compliance
Root Cause Analysis

Project Manager III

Business Support
 Oregon
12 Months

Location : Bend, OR The Project Manager III is responsible for leading and managing multiple projects from execution through completion while ensuring customer satisfaction, budget adherence, and timely delivery. The ideal candidate will have experience in HVAC and automation projects, strong leadership skills, and the ability to manage cross-functional teams in a fast-paced environment.

Project Management
HVAC
Automation
Customer Relationship Management
Budget Management
Stakeholder Management

Payroll Off-Cycle Specialist

Business Support
 Florida
3 Months

Location : Remote (FL The Payroll Off-Cycle Specialist is responsible for managing non-regular payroll runs, including bonus payments, terminations, retroactive adjustments, tax corrections, and special payroll projects. This role focuses on driving process improvements and automation initiatives while ensuring payroll accuracy, compliance, and operational efficiency. The ideal candidate will have strong payroll expertise, experience with SAP payroll systems, and a proven background in automation and process optimization projects.

Off-Cycle Payroll
SAP Employee Central Payroll
Process Automation
Payroll Compliance
Excel
Power Query
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