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

Digital Printer Operator

Business Support
 Ohio
$17-18/hr. on W2
03+ (Temp to Hire)

Location (mandatory): Parma OH 44130 Shift: Monday–Friday, 7am to 3:30pm This temp will be responsible for operating a high-speed digital production printer and helping with day-to-day duties, for example: Moving paper, stuffing envelope, packing cartons etc. Candidates should have some print experience, be detail-oriented, and be able to work in a fast-paced environment.

MS Office
Printer
Digital Printer
Scanner
Copier
Copying
Xerox
HP
Canon
Epson
Konica Minolta
Brother Industries
Electrophotographic
Inkjet

Associate, Warehouse/ Forklift Associate

Business Support
 California
$17-18/hr. on W2
12+ (Temp to Hire)

Location : Rialto, CA 92376 Shift: Monday–Friday, 6am to 3pm Seeking an experienced Warehouse Associate/Forklift Operator to support warehouse operations involving picking, packing, material handling, and inventory movement. Candidates must have prior forklift experience. Although client will provide the required forklift certification

Forklift
Warehouse
Picking
Shipping
Receiving
Sit Down Forklift
Stand-up Forklift
Reach Truck

Office Hospitality Specialist

Business Support
 California
$25-$28
05

Location : Palo Alto, CA 94304 The manager is prioritizing candidates with strong hospitality/customer service backgrounds who can confidently support executive-level clients, manage front-desk operations, and handle business center/mailroom responsibilities in a professional office environment.

Hospitality
Front Desk
Receptionist
Concierge
Customer Service
Conference Room Coordination
Mailroom
Shipping
Receiving
Office Services
Print Services
Copy Center
Document Management
Administrative Support
Legal Office
Client Relations

Receptionist / Legal Office Services Specialist

Business Support
 California
$25-$28
05

Location : Palo Alto, CA 94304 This role is best suited for someone who has worked as a Receptionist, Administrative Assistant, Front Desk Coordinator, Legal Receptionist, Executive Assistant, Office Coordinator, Concierge, or Guest Services Professional and is comfortable interacting with high-level legal professionals and clients in a fast-paced office setting. The manager is prioritizing professionalism, customer service, communication skills, reliability, and the ability to manage multiple responsibilities simultaneously.

Receptionist
Administrative Assistant
Front Desk Coordinator
Legal Receptionist
Executive Assistant
Office Coordinator
Concierge
Guest Services

Office Admin & Hospitality Specialist

Business Support
 New York
$23-24/hr. on W2
12+ (Temp to Hire)

This role is ideal for someone with strong customer service, communication, and front-office support experience. The selected candidate will serve as the first point of contact for guests and visitors, ensuring professional and welcoming experience while supporting office administration activities.

Hospitality Specialist
Meeting
Conference Room
Travel Arrangement
Office Admin
Office Specialist
Guest Management
Guest Relationship
Travel Arrangement

Office Services / Mailroom / Reprographics Specialist

Business Support
 New Jersey
$18-19/hr. on W2
03+ (Possibility of Temp to Hire)

Location : Mount Laurel, NJ 08054 Shift: Monday–Friday, 8am to 5pm Dress Code: Business Support This is not a legal or administrative assistant role. You will primarily work in a mailroom, copy center, and office services environment, supporting legal teams through document production, mail handling, shipping/receiving, and office support services. Experience with high-volume printing and copying is highly preferred.

Printing
Printer
Digital Printer
Copying
Scanning
Mailroom
UPS
USPS
FEDEX
Binding
Bindery
Shipping
Receiving

Administrative Assistant

Business Support
 California
$26.00-27.00
2 years

Location : San Diego, CA 92123 The role will provide administrative and operational support to Claims Management, including assisting with claim-related documentation, records, correspondence, data entry/tracking, running reports, checking and responding to department level voicemail, opening claims in the claim system, making check requests, and general administrative support to help maintain efficient department operations. They will also be responsible for supporting the department Senior Manager. This position will also be responsible for ensuring all required recovery claim documents are in the claim file including the damage report, police report when applicable, ISO report, bankruptcy checks, etc

administrative support
Claims Management
documentation
records
data entry/tracking

Claims Analyst: I

Business Support
 California
$30.00-35.00
2 years of Contract

Location : San Diego, CA 92123 The position investigates, analyzes, and resolves recovery/subrogation claims and may also handle liability and property damage claims. Responsibilities include gathering and analyzing evidence, interviewing involved parties, maintaining claim documentation, negotiating resolutions, pursuing recovery for damage to company property, and supporting claim setup and other administrative claim functions. The position has a $15,000 settlement authority threshold.

recovery/subrogation claims
property damage claims
casualty
subrogation

Print/ Mailroom Specialist

Business Support
 New York
$21-22/hr. on W2
03+ (Temp to Hire)

Location : New York, NY 10036 A reliable, customer-focused professional with hands-on experience in printing, scanning, mail services, shipping/receiving, and document production. Candidates with legal industry experience or print services backgrounds will be especially attractive to the hiring manager.

Printing
Printer
Digital Printer
Copying
Scanning
Mailroom
UPS
USPS
FEDEX
Binding
Bindery
Shipping
Receiving
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