SIU Investigative Support Specialist- Healthcare Related experience

About us:

Fallon Health is a company that cares. We prioritize our members-always-making sure they get the care they need and deserve. Founded in 1977 in Worcester, Massachusetts, Fallon Health delivers equitable, high-quality, coordinated care and is continually rated among the nation's top health plans for member experience, service, and clinical quality. We believe our individual differences, life experiences, knowledge, self-expression, and unique capabilities allow us to better serve our members. We embrace and encourage differences in age, race, ethnicity, gender identity and expression, physical and mental ability, sexual orientation, socio-economic status, and other characteristics that make people unique. Today, guided by our mission of improving health and inspiring hope, we strive to be the leading provider of government-sponsored health insurance programs-including Medicare, Medicaid, and PACE (Program of All-Inclusive Care for the Elderly)- in the region. Learn more at fallonhealth.org or follow us on Facebook, Twitter and LinkedIn.

Brief summary of purpose:

The SIU Investigative Support Specialist is an essential team member of the Special Investigation Unit ("SIU") that will be responsible for working less complex member and provider investigations related to fraud, waste, and abuse that will involve internal and external research and working with third parties and State and Federal agencies. This individual will be handling a substantial volume of documentation requests that need to be tracked and maintain such as incoming referrals, hotline tips, legal requests, and systemgenerated alerts that require screening, prioritization, and coordinate with internal to appropriately route requests. Working with SIU management to recover overpayments, write letters, check-in medical records and perform follow-up with providers. Assist in the development of department SIU Standards and policies and procedures, and maintenance; including documentation protocols, checklists, and filing procedures to ensure consistency, accessibility, and accuracy.

This individual will act as a trusted partner and a key liaison across internal and external stakeholders and regulatory agencies and will play a critical role in ensuring the investigative process move efficiently and consistently.

Primary Job Responsibilities:

The Internal Audit Department at Fallon Health serves as the organization's designated Special Investigation Unit (SIU). The SIU reports administratively to the Chief Compliance Officer and functionally to the Audit & Compliance Committee. The unit plays a critical role in safeguarding the organization by supporting fraud, waste, and abuse (FWA) detection, prevention, and investigative efforts.

Key Responsibilities

The SIU Investigative Support Specialist is an essential member of the Special Investigation Unit ("SIU") that will be responsible for working less complex member and provider investigations related to fraud, waste, and abuse that will involve internal and external research and working with third parties and State and Federal agencies.
• Oversee and manage a high volume of incoming referrals, hotline tips, and systemgenerated alerts.
• Work independently to screen, prioritize, and route referrals and alerts based on risk, regulatory urgency, financial impact and member impact.
• Support the development and maintenance of SIU casemanagement standards, including documentation protocols, checklists, and filing procedures to ensure consistency, accessibility, and accuracy.
• Handled incoming legal requests and coordinate appropriately with internal departments. This may include outreach to providers, members, collecting necessary information for investigations or case resolution. May require coordinating with internal departments such as Claims Ops, Clinical Services, Customer Service, Compliance, and external regulatory agencies without supervision.
• Monitor deadlines, milestones, and deliverables to ensure timely completion of assignments by SIU staff.
• Prepare SIU status reports, assist in data pulls, and support the production of periodic internal and external reports, including those required by CMS, EOHHS, and other regulators.
• Assist in the tracking of return on investments, and financial recovery efforts and sending out collection letters or payment plans.
• Take responsibility for interpreting regulatory requirements (CMS, MassHealth, EOHHS) and determining how they are operationalized within SIU workflows and how they should be incorporated into policy and procedures.
• Develop standard templates for provider communications, documentation requests, and official correspondence; draft, edit, and format letters, reports, presentations, and briefing materials.
• Oversee document management, including filing systems, case records, and recordsretention processes in alignment with organizational policies.
• Assist with operational logistics, implementation of SIU standards, and training coordination on behalf of SIU leadership.
• Maintain proper safeguarding of case files and SIU tools.
• Work independently to conduct background checks and support minor, lowcomplexity investigative tasks.
• Assist in the development of SIU policies, procedures, controls, and newsletter articles, plus assist in the development of presentations, and materials for training or reporting purposes.
• Serve as a key point of contact for MassHealth and external partners regarding case activity, as appropriate.
• Apply sound professional judgement, adhere to ethical standards, and maintain strict confidentiality when handling sensitive information.
• Handle confidential documentation and sensitive data and prioritize coming requests based on sense of urgency.
• Demonstrate an understanding of fraud investigation, program integrity, and regulatory compliance concepts.
• Participate in team meetings, trainings, and continuous improvement initiatives.
• Perform other duties as assigned.

Bachelor's degree preferred or equivalent experience.

• Required (minimum): 1-3 years' related experience in health insurance.
• Preferred: Related experience in audits/investigations/compliance.

Experience:

• Experience in healthcare, CMS programs, or MassHealth (EOHHSrelated environments) is a plus
• Exposure to fraud investigation, program integrity, auditing, or regulatory compliance concepts
• Familiarity with healthcare delivery systems, terminology or government programs
• Strong organizational and documentation skills, diligence to details, analytical thinking, with the ability to prioritize multiple tasks and met deadlines
• Strong analytical, problemsolving, and criticalthinking skills
• Excellent written and verbal communication abilities
• Strong administrative skills, with the ability to research and perform
• Proficiency with Microsoft Office Suite (Excel, Word, PowerPoint, Abode)
• Ability to work independently and collaboratively
• Ability to manage confidential information with discretion
• Research and datagathering proficiency
• Ethical judgment and confidentiality

Pay Range Disclosure:
In accordance with the Massachusetts Wage Transparency Act, the pay for this position is $ 65,000 - $72,000 annually which reflects what we reasonably and in good faith expect to pay at the time of posting. Final compensation will depend on the candidate's experience, skills, and fit with the role's responsibilities.

Fallon Health provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

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