About the Role
Title: SIU Investigator
Location: USA-
Job Description:
In order to apply for a position at Lumeris, you must create an account using your email address and a password of your choosing. This account will allow you to receive notifications each step of the way through the job application process. With these updates, you’ll never have to wonder where you are in the process. Additionally, we can easily send pertinent documents to you for your review. Once you create the account, you may apply to any position you feel is a good fit without having to re-enter information. Thank you for your interest in Lumeris.
Position Summary:
Responsible for assisting in the implementation and daily operation of the organization’s Special Investigations Unit (SIU) Program and all related activities for the Company’s Medicare Advantage and Prescription Drug health plan programs and its clients. Collaborates to investigate and resolve allegations of non-compliance, and to discover, investigate, and prevent fraud, waste, and abuse. 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:
Primary Responsibilities
- Conducts investigations into allegations of non-compliance, including marketing/sales and fraud, waste, and abuse. Researches, gathers information and evidence, and conducts timely and thorough interviews with team members at all levels. Disseminates information, resolves issues, and documents information relative to each incident.
- Works cross-functionally to identify potential incidents of non-compliance and appropriate corrective actions.
- Prepares written incident reports for review, to include incident details, status, resolution, root cause, and other pertinent information. Assists in preparing SIU activity monitoring reports.
- Presents status and findings in weekly internal and client meetings for discussion and direction.
- Identifies urgent and sensitive issues/incidents and escalates to facilitate appropriate and timely response.
- Monitors regulatory and hotline incident management systems for new incidents/inquiries. Responds timely and maintains accurate and thorough documentation in incidents systems. Adheres to established timeframes for completion and closure of incidents.
- Conducts marketing and sales surveillance to ensure compliance with Medicare Marketing Guidelines and internal policies and procedures.
- Maintains education, awareness, and knowledge of current regulations and best practices in the health care industry, specifically in investigation techniques and reporting.
- Assists in review and update of policies and procedures that meet regulatory and departmental requirements.
- Fosters and maintains good rapport with team members in all areas of the Company.
- Participates in team member education relative to SIU and compliance investigations, including creating presentations or other materials.
- Participates in compliance communication, awareness, education, and training activities to support the Compliance and SIU Programs.
- Assists in preparing for internal and regulatory audits, including the collection, preparation, and submission of SIU information, data, and documents to regulators and auditors.
- Participates in various team and committee meetings.
- Communicates the status of assignments/ projects at all levels, internally and externally.
- Other related duties as assigned.
Qualifications
- Bachelor’s degree in related field (i.e. Mathematics, Business, Health Information Administration, Statistics) or equivalent
- 3+ years of experience in investigations, compliance, healthcare operations, or the knowledge, skills, or abilities to succeed in the role
- Solid investigatory, critical thinking, and problem-solving skills
- Ability to organize, review, and effectively identify risk and appropriate response
- Firm interpersonal, collaboration, customer service, and oral/written communication skills with the ability to interact with team members at all levels
- Familiarity with healthcare laws, regulations, and standards
- Ability to research and interpret regulatory requirements
- Working knowledge of health plan operations, including customer service, claims processing, medical management, enrollment, and sales & marketing
- Skilled at meeting tight deadlines, being self-motivated and detail-oriented
- Good understanding of audits and corrective actions
- Ability to multi-task and operate effectively cross-functionally at all levels
- Ability to develop realistic goals, track progress, and adapt to changing priorities
- Capable of operating with high ethical and professional standards
Preferred:
- Experienced in a federally regulated environment, including Medicare Advantage, Medicaid, and/or managed care program experience