Special Investigations Unit (SIU) Investigator
SummaCare - 1200 E Market St, Akron, OH
Full-Time / 40 Hours / Days
Hybrid / Remote
Summary:
Conducts medium to high complexity investigations under general supervision to effectively pursue the identification, prevention, and investigation of healthcare fraud, waste and abuse (FWA), to facilitate the recovery of lost funds, and to comply with state and federal regulations mandating fraud plans and practices. Maintains knowledge of current schemes and determines impact to the plan. Ensures the SIU processes and procedures reflect current industry norms.
Formal Education Required:
a. Bachelor’s Degree, or equivalent combination of education and experience.
Experience & Training Required:
a. Five (5) years Fraud, Waste and Abuse identification and investigation.
b. Special Investigations Unit (SIU) experience in a managed care setting.
Essential Functions:
1) Works within industry groups, and known fraud, waste and abuse (FWA) data repositories to ensure a current knowledge and understanding of FWA schemes and industry practices.
2) Performs data mining to determine if identified FWA schemes are impacting the plan, summarize those findings and make recommendations for action including reporting and prevention. Documents all findings, decisions, and actions.
3) Maintains working knowledge of relative enterprise and local information systems, databases, data schemas, software packages, and business operations to facilitate precise, reliable and accurate fulfillment of information needs related to corporate operations.
4) Maintains employee, provider and member education as it relates to FWA.
5) Investigates assigned cases of FWA including coordinating and conducting on-site and desk-top audits, member and stakeholder interviews, outlier billing identification, contract and regulatory guidance analysis.
6) Manages the SIU prepay review process which includes requesting the implementation of prepay reviews, organizing the records, and reviewing submitted records or sending to the appropriate area for a medical/coding review.
7) Complies with SIU Policies and procedures as well as goals set by SIU leadership.
8) Prepares SIU documentation for arbitrations, legal procedures, and settlements.
9) Recommends claim handling based on medical record review and compliance with industry standard claim coding (CPT, HCPCs, ICD10. etc,) and payment policies.
10) Ability to effectively interact with populations of patients/customers with an understanding of their needs for self-respect and dignity.
3. Other Skills, Competencies and Qualifications:
a. Demonstrate intermediate proficiency in MS Office, Project, and database management.
b. Maintain excellent working knowledge of process improvement techniques, methodologies and principles applying these in the normal course of operations.
c. Demonstrate excellent analytical and problem-solving skills.
d. Apply principles of logical thinking to define problems, collect data, establish facts, and draw valid conclusions.
e. Organize and manage time to accurately complete tasks within designated time frames in fast paced environment.
f. Skilled at conducting analysis of claims data to identify aberrant patterns and support investigative activities.
g. Maintain current knowledge of and comply with regulatory and company policy and procedures.
h. Accredited Healthcare Fraud Investigator (AHFI) or Certified Fraud Examiner (CFE) preferred.
i. Lean Six Sigma Yellow Belt preferred
4. Level of Physical Demands:
a. Sit for prolonged periods of time.
b. Bend, stoop, and stretch.
c. Lift up to 20 pounds.
d. Manual dexterity to operate computer, phone, and standard office machines
As a regional, provider-owned health plan, SummaCare values the relationship between the members and their doctors. SummaCare is a part of Summa Health, an integrated healthcare delivery system that includes Summa Health System hospitals, its community-based health centers, dedicated clinicians and SummaCare. Based in Akron, Ohio, SummaCare provides Medicare Advantage, individual and family and commercial insurance plans. SummaCare has one of the highest rated Medicare Advantage plans in the state of Ohio, with a 4.5 out of 5-Star rating for 2025 by the Centers for Medicare and Medicaid Services (CMS). Known for its excellent customer service and personalized attention to members, SummaCare is committed to building lasting relationships. Employees can expect competitive pay and benefits.
Equal Opportunity Employer/Veterans/Disabled
$28.10/hr - $42.15/hr
The salary range on this job posting/advertising is base salary exclusive of any bonuses or differentials. Many factors, such as years of relevant experience and geographical location are considered when determining the starting rate of pay. We believe in the importance of pay equity and consider internal equity of our current team members when determining offers. Please keep in mind that the range that is listed is the full base salary range. Hiring at the maximum of the range would not be typical.
Summa Health offers a competitive and comprehensive benefits program to include medical, dental, vision, life, paid time off as well as many other benefits.