SIU Investigator IV

Medica – SIU Investigator IV Medica is a nonprofit health plan with more than a million members that serves communities in Minnesota, Nebraska, Wisconsin, Missouri, and beyond. We deliver personalized health care experiences and partner closely with providers to ensure members are genuinely cared for. We’re a team that owns our work with accountability, makes data‑driven decisions, embraces continuous learning, and celebrates collaboration – because success is a team sport. It’s our mission to be there in the moments that matter most for our members and employees. Join us in creating a community of connected care, where coordinated, quality service is the norm and every member feels valued. Job Overview The SIU Investigator IV leads advanced investigations into suspected fraud, waste, and abuse involving members, providers, and employees. The role manages complex cases, conducts specialized audits, and evaluates evidence that informs organizational, regulatory, and legal actions. It provides subject‑matter expertise, guides investigative approaches, and ensures SIU processes align with legal and compliance standards. The position has significant influence on investigative outcomes and supports team success through expert consultation and direction. Performs other duties as assigned. Key Accountabilities Lead Complex Fraud, Waste, and Abuse Investigations Direct investigative activities involving complex or high‑risk cases. Evaluate evidence from claims data, medical records, interviews, and external sources. Develop investigative conclusions and recommendations that support legal or administrative action. Prepare detailed case summaries that document findings, rationale, and next steps. Conduct Onsite Audits & Provider Reviews Plan and conduct onsite audits to assess compliance with billing, clinical, or operational standards. Analyze provider documentation and practices to identify irregularities or patterns of concern. Present audit results to stakeholders and recommend corrective actions. Maintain accurate, comprehensive documentation to support case continuity and regulatory needs. Serve as a SME with Legal, Regulatory & Law Enforcement Partners Collaborate with internal legal counsel on case strategies and regulatory considerations. Provide expert insights and case information to law enforcement and regulatory agencies. Represent SIU in external meetings, inquiries, or collaborative investigations. Respond to complex information requests with accuracy and timeliness. Guide SIU Investigative Processes & Contribute to Program Oversight Provide direction to team members on investigative methods, documentation standards, and case strategy. Identify process improvements that strengthen SIU effectiveness and compliance. Monitor investigative trends and risks to inform program planning and prevention efforts. Support development and adherence to SIU policies, procedures, and regulatory requirements. Support Knowledge Sharing & Capability Development within the SIU Mentor less experienced investigators on case management and investigative techniques. Share expertise on emerging fraud schemes, regulatory issues, and investigative best practices. Assist with training or education efforts for internal partners. Promote collaboration across the SIU to support consistent, high‑quality investigative work. Required Qualifications Bachelor’s degree or equivalent experience in a related field. 7+ years of previous investigative work experience beyond degree. Preferred Qualifications Health Care Anti‑Fraud Associate (HCAFA). Accredited Health Care Fraud Investigator (AHFI). Certified Fraud Examiner (CFE). Healthcare, health plan or provider SIU experience required. Proven investigatory skill; ability to organize, analyze, and effectively determine risk with corresponding solutions; ability to remain objective and separate facts from opinions. Knowledge of Managed Care and the Medicaid and Medicare programs as well as Marketplace. Fundamental understanding of audits and corrective actions. Understanding of claim billing codes, medical terminology, anatomy, and health care delivery systems. Effective interpersonal skills and customer service focus; ability to interact with individuals at all levels. Excellent oral and written communication skills; presentation skills with ability to create and deliver training, informational and other types of programs. Advanced skills in Microsoft Office (Word, Excel, PowerPoint, Outlook), SharePoint and intranet; proficiency with incorporating/merging documents from various applications. Ability to multi‑task and operate effectively across geographic and functional boundaries. Initiative, excellent follow‑through, persistence in locating and securing needed information. Strong logical, analytical, critical thinking and problem‑solving skills. Proven ability to research and interpret regulatory requirements. Understanding of data mining and use of data analytics to detect fraud, waste, and abuse. Detail‑oriented, self‑motivated, able to meet tight deadlines. Additional Information This position is an office role, which requires an employee to work onsite at our Minnetonka, MN office, on average, three days per week. The full salary grade for this position is $70,200 – $120,400. While the full salary grade is provided, the typical hiring salary range for this role is expected to be between $70,200 – $105,315. Annual salary range placement will depend on a variety of factors including, but not limited to, education, work experience, applicable certifications and/or licensure, the position’s scope and responsibility, internal pay equity and external market salary data. In addition to compensation, Medica offers a generous total rewards package that includes competitive medical, dental, vision, PTO, Holidays, paid volunteer time off, 401(k) contributions, caregiver services and many other benefits to support our employees. Eligibility to work in the United States: Medica does not offer work visa sponsorship for this role. All candidates must be legally authorized to work in the United States at the time of application. Employment is contingent on verification of identity and eligibility to work in the United States. We are an Equal Opportunity Employer. All qualified candidates receive consideration for employment regardless of race, religion, ethnicity, national origin, citizenship, gender, gender identity, sexual orientation, age, veteran status, disability, genetic information, or any other protected characteristic. #J-18808-Ljbffr Medica