What are the responsibilities and job description for the RN Special Investigations Unit (SIU) Investigator position at Summa Health?
SummaCare is a Summa Health entity that offers health insurance in northern Ohio. As a regional, provider-owned health plan, SummaCare is based in Akron, Ohio, and provides Medicare Advantage, individual and family and commercial insurance plans. SummaCare has one of the highest rated Medicare Advantage plans in the state of Ohio, with a 4.5 out of 5-Star rating for 2025 by the Centers for Medicare and Medicaid Services (CMS). Known for its excellent customer service and personalized attention to members, SummaCare is committed to building lasting relationships. Employees can expect competitive pay and benefits.
Conducts medium to high complexity investigations under general supervision to effectively pursue the identification, prevention, and investigation of healthcare fraud, waste and abuse (FWA), to facilitate the recovery of lost funds, and to comply with state and federal regulations mandating fraud plans and practices. Skilled at conducting analysis of claims data, medical records and claims coding to identify aberrant patterns and support investigative activities. Maintains knowledge of current schemes and determines impact to the plan. Ensures the SIU processes and procedures reflect current industry norms.
Formal Education Required :
a. Bachelor’s Degree, or equivalent combination of education and experience.
b. Registered Nurse (RN) license in good standing
Experience & Training Required :
a. Five (5) years health insurance experience to include: clinical review of medical records, analysis, report development, database administration, claims coding, and Fraud, Waste and Abuse identification and investigation.
b. Certified Professional Coder with one (1) years of experience reviewing medical records
c. Accredited Healthcare Fraud Investigator (AHFI) certification preferred.
d. Special Investigations Unit (SIU) experience in a managed care setting.
e. LSS Yellow Belt Certified preferred.
Other Skills, Competencies and Qualifications:
a. Demonstrate intermediate proficiency in MS Office, Project, and database management.
b. Maintain excellent working knowledge of process improvement techniques, methodologies and principles applying these in the normal course of operations.
c. Demonstrate excellent analytical and problem-solving skills.
d. Effectively conduct statistical analyses and accurately work with large amounts of data.
e. Apply principles of logical thinking to define problems, collect data, establish facts, and draw valid conclusions.
f. Organize and manage time to accurately complete tasks within designated time frames in fast paced environment.
g. Maintain current knowledge of and comply with regulatory and company policy and procedures.
Level of Physical Demands:
a. Sit for prolonged periods of time.
b. Bend, stoop, and stretch.
c. Lift up to 20 pounds.
d. Manual dexterity to operate computer, phone, and standard office machines.
Equal Opportunity Employer/Veterans/Disabled
The salary range on this job posting/advertising is base salary exclusive of any bonuses or differentials. Many factors, such as years of relevant experience and geographical location are considered when determining the starting rate of pay. We believe in the importance of pay equity and consider internal equity of our current team members when determining offers. Please keep in mind that the range that is listed is the full base salary range. Hiring at the maximum of the range would not be typical.
Salary : $31 - $46
