Siu auditor

Role Overview:

The SIU Auditor is responsible for conducting comprehensive investigations of reported, alleged or suspected fraud involving the full range of products at the AmeriHealth Caritas Family of Companies (ACFC).

Work Arrangement:

Remote within the United States with Delaware residency preferred. For roles that are 100% remote or hybrid, you must have access to a reliable high-speed internet connection to support daily job responsibilities. A minimum bandwidth of 50 Mbps download and 5 Mbps upload is required. Those fully remote associates residing in states where service is required by contract, law, or regulation will be allowed to submit for reimbursement.

Responsibilities:

• Ensures compliance with all requirements related to Special Investigation Units and fraud, waste and abuse investigations.
• Conducts comprehensive interviews with providers, members and witnesses to obtain information which would be considered admissible under generally accepted criminal and civil rules of evidence.
• Proactively performs research using the Internet, data analysis tools, etc., to analyze aberrant claims billing and practice patterns.
• Conducts proactive data mining and analyzes data as part of the investigative process using available fraud detection software and corporate resources.
• Prepares and submits investigative reports covering all phases of the investigation.
• Interprets and conveys highly technical information to others.
• Establishes and maintains liaison with public officials, law enforcement and others to obtain assistance in conducting investigations.
• Knowledge of available resources (internal and external) to assist in investigations.

Education/Experience:

Bachelor’s Degree preferred or equivalent work experience in healthcare-related fields. 1+ years of Auditing experience or related experience in healthcare. Medicaid experience preferred. SIU and/or State Medicaid regulatory compliance work experience a plus. Knowledge and proficiency in claims adjudication standards & procedures preferred. Experience with Medicaid, Medicare, and/or pharmacy benefit reimbursement. Specific experience required driven by business needs. Solid knowledge of Medicaid, Medicare, and pharmacy benefit laws and requirements; federal, state, civil and criminal statutes. Experience with decision support tools used for data analysis. Advanced knowledge and experience working on various approaches to fraud, waste and abuse. Working knowledge of Microsoft applications, especially Excel required. Analytical skills and ability to make deductions; logical and sequential thinker. Experience with LTSS preferred. Valid driver’s license required. Strong verbal and written communication skills.

Our Comprehensive Benefits Package

Flexible work solutions including remote options, hybrid work schedules, Competitive pay, Paid time off including holidays and volunteer events, Health insurance coverage for you and your dependents on Day 1, 401(k) Tuition reimbursement and more.

Your career starts now. We’re looking for the next generation of health care leaders. At AmeriHealth Caritas, we’re passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we’d like to hear from you.

Headquartered in Newtown Square, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services.

Discover more about us at www.amerihealthcaritas.com.