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Company Contact Info

  • 3250 Mary Street
    Miami, FL 33133
  • Giovanny Flores
  • Phone: 305-448-8100
  • Phone:: 305-489-8006

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SIU Investigator

HealthSun Health Plans • Miami, FL

Posted 26 days ago

Job Snapshot

Travel - None
Experience - At least 2 year(s)
Degree - 4 Year Degree
Health Care
Relocation - No


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Job Description

HealthSun Health Plans is seeking energetic,talented and qualified professionals to join us in our mission of changing the healthcare experience of our members - making it easier, friendlier and more accessible.  If you are looking for a challenging and rewarding career with a chance to make a real difference in your community, please apply.

HealthSun Health Plans is headquartered in the Coconut Grove area of Miami, Florida supporting the needs of Medicare Advantage recipients throughout South Florida. We are proud to offer outstanding career advancement opportunities, competitive salaries, paid holidays, medical & dental insurance plans, Paid Time Off, disability benefits, and a 401(k) retirement savings plan.

Responsible for detecting and investigating Fraud, Waste and Abuse and providing feedback on network behavior to the plan. Responsible for the development of action plans based upon findings and executing the plan with the appropriate internal and external resources to conclusion. Additionally responsible for developing ongoing controls based upon historical findings to reduce future risks. 

  • Conducts investigations of fraud, waste and abuse. Including: conducting interviews and on-site pharmacy visits, as well as reporting and responding to regulators and law enforcement. 
  • Ensures compliance with HIPAA regulations and requirements.  
  • Develops reports of investigation findings, compiles accurate case file documentation, calculates overpayments, conducts and documents interviews. 
  • Reviews and analyzes investigation materials such as patient charts, business records, financial ledgers, and claims data in conjunction with applicable regulations, contracts and policy manuals. 
  • Contacts members, pharmacies, providers, and third parties via telephone interview and/or letter to validate claim submissions. 
  • Supports internal compliance reviews as appropriate, including accurate tracking of case information and timely reporting as needed for external audits and regulatory oversight. 
  • Provides case updates on progress of investigations and coordinates with SIU Manager and team members on recommendations and further actions and/or resolution, as needed.
  • Serves as a resource for departments to research and resolve integrity inquiries and abusive billing issues.
  • Performs data mining and analyses to detect aberrancies/outliers in claims and data in order to proactively seek out and report Medicare FWA.
  • Develops audit rules and queries to pull data for potential FWA activity from data mart. 
  • Identifies and recommends policy, procedure, and systems changes to enhance investigative outcomes and performance. 
  • Responsible for meeting all regulatory and departmental deadlines.
  • Suggests integrity measures and conducts routine audits. 
  • Communicates effectively with other professional and support staff in order to achieve positive customer outcomes.
  • Promotes and contributes to a positive, problem-solving environment.
  • Complies with company policies and procedures and maintains confidentiality of customer medical records in accordance with state and federal laws.
  • Ensures compliance with all HIPAA, OSHA, and other federal, state, and local regulations. 
  • Participates in meetings, training and in-service education, as required. 
  • Performs other duties as assigned.

Job Requirements

  • Minimum of High School Diploma or equivalent
  • Bachelor’s degree in Business, Finance, or related field from an accredited college or university preferred
  • Minimum of 2 years in a Managed Care Setting
  • Knowledge of SHMS is preferred
  • Proficiency in analyzing, understanding and communicating financial trends
  • Excellent computer knowledge is required, including proficient knowledge of Microsoft Office
  • Excellent listening, interpersonal, verbal and written communication skills with individuals at all levels of the organization
  • Ability to work effectively independently and in a team environment
  • Ability to read, analyze, and interpret technical procedures or governmental regulations
  • Ability to write reports, business correspondence, and procedure manuals
  • Ability to effectively present information and respond to questions from groups of managers, clients, customers and the general public
  • Ability to calculate figures and amounts, such as discounts, interest, commissions, proportions, percentages, area and volume
  • Ability to define problems, collect data, establish facts, and draw valid conclusions
  • Strong decision-making, analytical skills
  • Must be self-motivated, organized and have excellent prioritization skills
  • Must be able to work well under stressful conditions
  • Must be able to work in a fast paced environment
  • Fluency in Spanish and English required

HealthSun Health Plans and its affiliated companies is an equal opportunity/affirmative action employer and complies with all federal and state laws, regulations and executive orders regarding affirmative action requirements in all programs.M/F/D/V.

HealthSun and its affiliates are also a drug-free workplace.

*Internal candidates must submit the Internal Application Form approved by his/her supervisor before interviewing with HR. Qualified candidates will be considered by the Hiring Manager.

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