JOB SUMMARY
The SIU Investigator is responsible for detecting, investigating, and preventing potential fraud, waste, and abuse (FWA) within claims and provider billing. This role conducts pre- and post-payment reviews, coordinates investigative efforts with internal and external stakeholders, and prepares detailed reports with findings and recommendations. The Investigator also educates providers and staff on compliance and proper coding practices while ensuring adherence to federal and state regulations.

JOB SPECIFICATIONS
Claims Investigation & Pre-Payment Review
Provide timely review and disposition of suspected case referrals, including determining alleged upcoding or unbundling of services. Review claim lines flagged by the SIU contractor and issue `do-not-pay' recommendations when appropriate. Gather and analyze claims data, medical records, contracts, and public records to determine if further action or formal investigation is warranted.

Findings Development & Reporting
Develop and present findings and recommendations on the appropriateness of diagnosis and procedure codes submitted on provider service claims. Support discussions regarding potential overpayments with providers and Community's Fraud, Waste, and Abuse (FWA) Committee. Ensure the timely preparation and submission of required regulatory reports.

Communication & Regulatory Liaison
Communicate review outcomes and the rationale for determinations clearly and professionally to providers, Community Health Choice (CHC) staff, the FWA Committee, and regulatory agencies such as the Office of Inspector General (OIG) and the Texas Attorney General's office.

Education & Compliance Training
Educate providers, suppliers, pharmacies, and administrative staff on CMS, federal, and state statutory, regulatory, and contractual requirements. Deliver training on appropriate coding per AMA guidelines, acceptable practice standards, and procedures for preventing and reporting potential fraud and abuse. Present educational seminars on fraud and abuse awareness, detection, and reporting as required.

Actively contributes to the achievement of departmental goals, as identified in the Department's annual business plan, including specific departmental process improvement plans. Other duties as assigned.

QUALIFICATIONS:
' Education/Specialized Training/Licensure: Bachelor's degree required
' Must hold one of the following certifications: AHFI, or CFE (or equivalent). AHFI or CFE certification may be obtained within one year of employment if not already held required.
' CPC (or equivalent) certification preferred
' Work Experience (Years and Area): Minimum of 2 years' experience in healthcare investigations and/or medical coding, utilization management, or medical record auditing.
' Solid knowledge of Medicare, Medicaid, commercial insurance investigations and coding practices.
' Software Proficiencies: Proficiency in Microsoft Office (Word, Excel, Outlook) and claims processing systems required.
' Claims processing systems preferred.
' Other: Certified Fraud Investigator: Medical coding procedure expertise (CPT, ICD-10, HCPCS).
' Strong analytical, problem-solving, and decision-making abilities.
' Excellent verbal and written communication skills.
' Attention to detail, accuracy, and ability to handle confidential information.
' Certification in Coding and Medical Billing preferred.