Senior Special Investigative Unit (SIU) Auditor
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What you'll do
- Conduct retrospective and prospective audits of medical claims, provider billing, coding, and clinical documentation.
- Validate CPT, HCPCS, ICD-10-CM, DRG, modifier, and revenue code accuracy and reimbursement compliance.
- Apply knowledge of medical terminology, anatomy, physiology, and disease processes when evaluating records.
- Analyze billing trends and data to identify suspicious activity, improper reimbursement, and emerging risk.
- Develop fraud prevention strategies and support provider education, remediation, and corrective action.
- Use sound judgment to independently investigate complex issues and recommend next steps.
- Prepare clear audit findings, overpayment determinations, investigative documentation, and recommendations for leadership.
- Maintain confidentiality, chain-of-custody standards, and compliance with applicable laws, regulations, and coding guidance.
- Manage multiple audits and investigations, coordinating priorities, timelines, deliverables, and stakeholder communication.
- Collaborate with internal and external partners and provide affidavits or sworn testimony when needed.
- Mentor junior auditors and lead process improvements and proactive audit initiatives.
What they're looking for
- Bachelor’s degree in a related field or an equivalent combination of education and relevant experience
- 5 years of healthcare coding, auditing, SIU, compliance investigation, claims analysis, appeals, provider dispute, or related experience
- Active Certified Professional Coder (CPC) and Accredited Healthcare Fraud Investigator (AHFI) credentials
Nice to have
- Additional certification such as CPC-P, CPMA, CCS, CFE, or CHC preferred
Summarised by NextRaise from the employer’s description, which follows in full below.
Full description from employer
Workforce Classification:
Hybrid
Join Our Team: Do Meaningful Work and Improve People’s Lives
Our purpose, to improve customers’ lives by making healthcare work better, is far from ordinary. And so are our employees. Working at Premera means you have the opportunity to drive real change by transforming healthcare.
Premera is committed to being a workplace where people feel empowered to grow, innovate, and lead with purpose. By investing in our employees and fostering a culture of collaboration and continuous development, we’re able to better serve our customers. It’s this commitment that has earned us recognition as one of the best companies to work for. Learn more about our recent awards and recognitions as a greatest workplace.
Learn how Premera supports our members, customers and the communities that we serve through our Healthsource blog: https://healthsource.premera.com/.
The Senior Special Investigative Unit (SIU) Auditor investigates and audits potential healthcare fraud, waste, abuse, and coding irregularities across claims, billing, documentation, and reimbursement. This role requires advanced auditing expertise, industry-specific investigative knowledge, and sound judgment to identify and address improper billing and reimbursement. You will also lead proactive audit initiatives that strengthen oversight and protect the integrity of the claims process.
What You’ll Do
Audit and Coding Review
- Conduct retrospective and prospective audits of medical claims, provider billing, coding, and clinical documentation.
- Validate CPT, HCPCS, ICD-10-CM, DRG, modifier, and revenue code accuracy and reimbursement compliance.
- Apply knowledge of medical terminology, anatomy, physiology, and disease processes when evaluating records.
Investigative Analysis and Fraud Prevention
- Analyze billing trends and data to identify suspicious activity, improper reimbursement, and emerging risk.
- Develop fraud prevention strategies and support provider education, remediation, and corrective action.
- Use sound judgment to independently investigate complex issues and recommend next steps.
Reporting, Compliance, and Case Documentation
- Prepare clear audit findings, overpayment determinations, investigative documentation, and recommendations for leadership.
- Maintain confidentiality, chain-of-custody standards, and compliance with applicable laws, regulations, and coding guidance.
Legal Support, Collaboration, and Operational Execution
- Manage multiple audits and investigations, coordinating priorities, timelines, deliverables, and stakeholder communication.
- Collaborate with internal and external partners and provide affidavits or sworn testimony when needed.
- Mentor junior auditors and lead process improvements and proactive audit initiatives.
What you’ll bring:
- Bachelor’s degree in a related field or an equivalent combination of education and relevant experience (Required)
- 5 years of healthcare coding, auditing, SIU, compliance investigation, claims analysis, appeals, provider dispute, or related experience (Required)
- Active Certified Professional Coder (CPC) and Accredited Healthcare Fraud Investigator (AHFI) credentials (Required)
- Additional certification such as CPC-P, CPMA, CCS, CFE, or CHC preferred
- Experience with SIU case management systems, SQL, Excel, and data analytics or audit tools.
- Advanced knowledge of coding methodologies, healthcare compliance requirements, and fraud, waste, and abuse indicators.
- Strong analytical, problem-solving, communication, and presentation skills.
Premera total rewards
Our comprehensive total rewards package provides support, resources, and opportunities to help employees thrive and grow. Our total rewards are more than a collection of perks, they're a reflection of our commitment to your health and well-being. We offer a broad array of rewards including physical, financial, emotional, and community benefits, including:
Medical, vision, and dental coverage with low employee premiums.
Voluntary benefit offerings, including pet insurance for paw parents.
Life and disability insurance.
Retirement programs, including a 401K employer match and, believe it or not, a pension plan that is vested after 3 years of service.
Wellness incentives with a wide range of mental well-being resources for you and your dependents, including counseling services, stress management programs, and mindfulness programs, just to name a few.
Generous paid time off to reenergize.
Looking for continuing education? We have tuition assistance for both undergraduate and graduate degrees.
Employee recognition program to celebrate anniversaries, team accomplishments, and more.
For our hybrid employees, our on-campus model provides flexibility to create your own routine with access to on-site resources, networking opportunities, and team engagement.
Commuter perks make your trip to work less impactful on the environment and your wallet.
Free convenient on-site parking.
Subsidized on-campus cafes make lunchtime connections with colleagues fun and affordable.
Participate in engaging on-site activities such as health and wellness events, coffee connects, disaster preparedness fairs and more.
Our complementary fitness & well-being center offers both in-person and virtual workouts and nutritional counseling.
Need a brain break? Challenge someone to a game of shuffleboard or ping pong while on campus.
Equal employment opportunity/affirmative action:
Premera is an equal opportunity/affirmative action employer. Premera seeks to attract and retain the most qualified individuals without regard to race, color, religion, sex, national origin, age, disability, marital status, veteran status, gender or gender identity, sexual orientation, genetic information or any other protected characteristic under applicable law.
If you need an accommodation to apply online for positions at Premera, please contact Premera Human Resources via email at careers@premera.com or via phone at 425-918-4785.
The pay for this role will vary based on a range of factors including, but not limited to, a candidate’s geographic location, market conditions, and specific skills and experience.
The salary range for this role is posted below; we generally target up to and around the midpoint of the range.
National Plus Salary Range:
$69,600.00 - $118,300.00*National Plus salary range is used in higher cost of labor markets including Western Washington and Alaska.
We’re happy to discuss compensation further during the interview because we believe that open communication leads to better outcomes for all. We’re committed to creating an environment where all employees are celebrated for their unique skills and contributions.
Company
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