Senior Investigator

About SCAN

SCAN Group is a not-for-profit organization dedicated to tackling the most pressing issues facing older adults in the United States. SCAN Group is the sole corporate member of SCAN Health Plan, one of the nation's leading not-for-profit Medicare Advantage plans, serving more than 300,000 members in California, Arizona, Nevada, Texas and New Mexico. SCAN has been a mission-driven organization dedicated to keeping seniors healthy and independent for more than 45 years and is known throughout the healthcare industry and nationally as a leading expert in senior healthcare. SCAN employees are a group of talented, passionate professionals who are committed to supporting older adults on their aging journey, while also innovating healthcare for seniors everywhere. Employees are provided in-depth training and access to state-of-the-art tools necessary to do their jobs, as well as development and growth opportunities. SCAN takes great pride in recognizing our team members as experts in their fields and rewarding them for their efforts. If you are interested in becoming part of an organization that is innovating senior healthcare visit www.thescangroup.org, www.scanhealthplan.com, or follow us on LinkedIn, Facebook, and Twitter.

The Job

The Senior Investigator position reports directly to the SIU Strategic Project Professional. The successful candidate will work to identify, mitigate, and prevent improper payments by conducting thorough fraud, waste, and abuse investigations and recommending internal and external actions to remediate identified issues.

You Will

Lead fraud, waste, and abuse investigations and develop corrective actions, including recovering overpayments, drafting provider education, and recommending internal controls to prevent improper payments as appropriate.

Analyze data to identify potential billing aberrancies or fraudulent patterns that require additional investigation.

Perform desk audits of medical records and facilitate medical necessity reviews by SCAN Medical Directors.

Conduct member and provider interviews.

Document all investigative actions in the case management system.

Head meetings with operational departments, business partners, and regulatory partners.

Draft regulatory fraud, waste, and abuse referrals to federal and state Medicare/Medicaid agencies.

Establish and maintain relationships with Federal and State law enforcement agencies, task force members, SIU staff, and external contacts involved in investigations.

Develop educational materials for internal staff on healthcare fraud, waste, and abuse and the SIU's role within the organization.

We seek Rebels who are curious about AI and its power to transform how we operate and serve our members.

Actively support the achievement of SCAN's Vision and Goals.

Other duties as assigned.

Your Qualifications

Bachelor's Degree or equivalent experience

Preferred Certifications or Licenses:
Accredited Health Care Fraud Investigator (AHFI), Certified Fraud Examiner (CFE), Certified Professional Coder (CPC), or other coding credential(s) desired but not required.

Experience Preferred:
5 - 7 years of healthcare fraud, waste, and abuse investigations or related experience.
Previous Medicare/Medicaid investigations experience.

Technical expertise - Advanced analytical skills

Problem Solving - Basic problem-solving skills

Communication - Good communication and interpersonal skills

Working knowledge of health plan operations, claim processing, medical terminology, and coding (CPT, HCPCS, ICD).

Proficiency in Microsoft Office with advanced skills in Excel (must know how to do pivot tables).

Strong analytical and research skills.

Excellent problem solving and decision-making skills with attention to details.

Strong verbal and written communication skills.

A high degree of integrity and confidentiality is required for handling information that is considered personal and confidential.

What's in it for you?
* Base salary range: $106,200 to $151,910 per year
* Work Mode - Remote
* An annual employee bonus program
* Robust Wellness Program
* Generous paid-time-off (PTO)
* Eleven paid holidays per year, plus 1 floating holiday, plus 1 birthday holiday
* Excellent 401(k) Retirement Saving Plan with employer match and contribution
* Robust employee recognition program
* Tuition reimbursement
* An opportunity to become part of a team that makes a difference to our members and our community every day!

We're always looking for talented people to join our team! Qualified applicants are encouraged to apply now!

At SCAN we believe that it is our business to improve the state of our world. Each of us has a responsibility to drive Equality in our communities and workplaces. We are committed to creating a workforce that reflects our community through inclusive programs and initiatives such as equal pay, employee resource groups, inclusive benefits, and more.

SCAN is proud to be an Equal Employment Opportunity and Affirmative Action workplace. Individuals seeking employment will receive consideration for employment without regard to race, color, national origin, religion, age, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender perception or identity, age, marital status, disability, protected veteran status or any other status protected by law. A background check is required.

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