SIU Investigator III

CareSource Management Group Company

Job Overview

Location

Remote

Job Type

Full-time

Full Job Description

📋 Description

• The SIU Investigator III role at CareSource is a critical position responsible for leading high-complexity investigations into healthcare fraud, waste, and abuse (FWA), directly protecting the integrity of Medicaid, Medicare, and ACA/Exchange programs and safeguarding public and organizational funds by identifying fraudulent billing patterns and ensuring compliance with federal and state regulations.
• This role serves as a subject matter expert and strategic leader within the Special Investigations Unit, driving fact-based investigative initiatives, mentoring junior staff, and collaborating with legal, regulatory, and law enforcement partners to build actionable cases that result in financial recoveries, corrective actions, and systemic improvements.
• Day-to-day responsibilities include developing and executing strategic investigative projects using claims, eligibility, pharmacy, and clinical data; managing the production and validation of analytical reports; conducting on-site and desk audits of medical records; preparing and leading complex interviews with providers and members; managing pended claims; developing and overseeing corrective action plans; and presenting findings to legal and executive stakeholders for litigation or settlement proceedings.
• The investigator ensures quality and consistency across the team by auditing investigative work, prioritizing caseloads, tracking investigation status, and reporting financial impact to leadership, while maintaining strict confidentiality and adherence to CareSource’s Corporate Compliance and Anti-Fraud Plans.
• Collaboration is central to the role, involving regular engagement with data analytics teams to apply RAT STATS and statistically valid random sampling techniques, partnering with operational and regulatory departments, and building relationships with federal and state law enforcement agencies, task forces, and external fraud prevention networks.
• The role requires deep expertise in healthcare billing systems, including fluency in CPT, HCPCS, and ICD coding guidelines, as well as the ability to interpret state-specific Medicaid, federal Medicare, and ACA/Exchange laws, rules, and medical standards to support accurate and defensible investigative conclusions.
• Investigators in this role develop advanced skills in data-driven fraud detection, complex case management, legal documentation, and interagency coordination, positioning them as trusted experts capable of influencing policy, driving recoveries, and contributing to national healthcare integrity efforts.
• Professionals in this role gain mastery in blending analytical rigor with investigative intuition, learning to translate data anomalies into compelling narratives that withstand legal scrutiny and drive meaningful change in healthcare accountability.

🎯 Requirements

• Bachelor’s Degree or equivalent experience in a health-related field, law enforcement, or insurance; Master’s Degree preferred in criminal justice, public health, mathematics, statistics, health economics, or nursing.
• Minimum of five (5) years of experience in healthcare fraud investigations, medical coding, pharmacy, medical research, auditing, data analytics, or a related field.
• Required certification: Accredited Healthcare Fraud Investigator (AHFI) or Certified Fraud Examiner (CFE); Certified Professional Coder (CPC) preferred.

🏖️ Benefits

• Competitive salary range of $72,200.00 to $115,500.00, with potential for performance-based bonuses tied to company and individual achievements.
• Comprehensive total rewards package supporting employee well-being, including health, dental, vision, retirement savings, and paid time off.
• Opportunities for professional development through attendance at fraud, waste, and abuse training sessions and conferences, as needed.
• Remote work flexibility with occasional travel (up to 10%) for meetings, training, and conferences.

Skills & Technologies

Remote

Degree Required

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CareSource Management Group Company

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About CareSource Management Group Company

CareSource is a nonprofit, multi-state managed care organization headquartered in Dayton, Ohio. Founded in 1989, it administers Medicaid, Medicare Advantage, and Marketplace health plans serving over two million members in Ohio, Kentucky, Indiana, West Virginia, and Georgia. The company focuses on improving health outcomes for low-income and vulnerable populations through integrated care management, behavioral health services, and social determinants programs.

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