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FULL REMOTE - Health Insurance Fraud Investigator

OPEN JOB: FULL REMOTE - Health Insurance Fraud Investigator
Salary to $90,396

Benefits - Full

Seeking a health insurance Investigator, Special Investigation Unit who will:
  • Support timely completion of compliance related audits and investigations of the Special Investigations Unit (SIU) at the Health Plan
  • Collaborate with and learn from subject matter experts to identify, investigate and correct fraudulent and/or abusive billing and coding practices, which may advance in complexity with experience
  • Leverage credible sources of information from Internet research in case preparation
  • Proactively learns and applies data analysis related to fraud risk identification and prevention
  • Able to manage a workload with multiple cases and audits simultaneously
  • May assist Senior Investigator or SIU Director in developing, implementing and performing compliance related auditing and monitoring activities at the Health Plan
  • Coordinate recovery of overpayments related to fraudulent and/or abusive billing and coding practices; keeps organized audit work papers that enables collaboration with external teams in the audit and recovery process
  • Coordinate with parties with compliance accountabilities to facilitate corrective action completion and behavior change
  • Provide education related to coding, medical record documentation requirements, healthcare compliance and fraud, waste and abuse to Health Plan staff, vendors and contracted providers/facilities
  • Support team in peer review and delivery of quality work product, including integrating checks on their own work product
  • Presents on fraud risk in a professional manner, in written and oral reports, tailored to providers, executives, members, and regulators
  • Submit timely and professional reports of case findings to regulators, law enforcement, and internal business partners
  • Provide training on fraud prevention to executives, caregivers, business partners, and members
  • Supports timely processing of risk report intake triage, timely processing of prepay audit claims, and other compliance requirements

Required qualifications for this position include:
  • Bachelor's Degree -OR- a combination of equivalent education and experience
  • 5+ years coding experience at a healthcare provider, facility or health insurance company
  • 2+ years fraud and abuse audit experience at a health plan, health insurance company, healthcare provider, facility or other relevant healthcare environment
  • Project management experience, education program development experience and group presentation experience
  • Experience in use of data mining software/tools

Preferred qualifications for this position include:
  • Current certification as Certified Coding Professional (CPC)
  • Current certification in health care fraud investigation, such as Accredited Healthcare Fraud Investigator (AHFI), Certification as an Internal Auditor (CIA), Healthcare Compliance certification (CHC), or equivalent
  • Basic understanding of statistics and data analytics
  • Basic understanding of analytics software (e.g.: SQL, Power BI, MS Access, Tableau, Alteryx) or a demonstrated interest in learning analytics software
  • Advanced understanding of MS Excel and PowerPoint
  • Professional communication skills, representing the SIU in verbal and written communications with executives, law enforcement, regulators, attorneys, physicians, members, etc.

If you are interested in pursuing this opportunity, please respond back and include the following:
  • MS WORD Resume
  • required compensation.
  • Contact information.
  • Availability
Upon receipt, one of our managers will contact you to discuss the position in full detail.

Recruiting Manager

EMAIL: jdenmark@intermediagroup.com
LINKEDIN: https://www.linkedin.com/in/jasondenmark

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