SIU Investigator

Kforce has a client in the Healthcare industry in Los Angeles who is looking for a SIU Investigator.

Responsibilities:

• Reviews allegations and complex issues related to potential healthcare fraud, waste, and abuse involving providers, pharmacies, employers, and members
• Analyzes claims data, provider information, and other available records to identify unusual billing patterns, trends, and potential areas of concern
• Conducts research and gathers relevant information from a variety of internal and external sources, including fraud tips, referrals, public records, industry publications, and media reports
• Documents investigative activities, findings, interviews, and supporting evidence in detailed written reports and summaries
• Reviews information contained within claims processing systems, provider files, and related databases to identify billing anomalies and potential compliance concerns
• Participates in onsite reviews, audits, and information-gathering activities as assigned
• Maintains documentation and case files in accordance with organizational policies, confidentiality requirements, and regulatory guidelines
• Prepares reports and supporting documentation for internal stakeholders and designated regulatory or compliance teams as appropriate
• Responds to requests for information and assists with ongoing case tracking and documentation
• Participates in industry meetings, professional development activities, and training programs to stay informed of emerging fraud trends and investigative techniques
• Develops and maintains effective working relationships with internal departments, regulatory agencies, and other external stakeholders
• Applies subject matter expertise to support business operations, process improvement efforts, and investigative reviews
• Identifies opportunities to enhance workflows, reporting, and analytical processes
• Provides guidance, knowledge sharing, and training support to team members as needed