SIU Investigator

Location

Doral, FL

Job Type

Full-time

POSITION SUMMARY

Responsiblefor investigations related to suspected Fraud, Waste and Abuse to ensure compliancewith Federal, State, Centers for Medicare and Medicare (CMS) and contractualrequirements and regulations.

ESSENTIAL DUTIES &RESPONSIBILITIES

• Assist with the development of SIU investigation policies and procedures
• Ensures weekly monitoring of investigative case load to ensure compliance with department policies related to case timelines
• Coordinates with all internal departments and subcontractors to collect and collate information, and investigate all identified cases of suspected FWA
• Requests and tracks the status of medical record request as part of the investigative process
• Sends prepayment review notifications and overpayment notifications, when appropriate
• Provides case updates on progress of investigations and makes recommendations related to cases to management
• Participates in the development of internal Fraud Alerts for company-wide distribution.
• Contacts members, providers, and third parties via telephone interview and/or letter to validate claim submissions
• Conducts/assists with on-site audits of FWA activities
• Supports internal compliance reviews as appropriate, including accurate tracking of case information and timely reporting as needed for external audits and regulatory oversight
• Serves as a resource for departments to research and resolve integrity inquiries and abusive billing issues
• Performs data mining and analyses to detect aberrancies/outliers in claims and data in order to proactively seek out and report FWA
• Arranges and conducts meetings with providers, employees, business partners, and where appropriate, representatives from regulatory agencies and law enforcement with investigations
• Identifies and recommends policy, procedure, and systems changes to enhance investigative outcomes and performance
• Suggests integrity measures and assist the department in conducting routine audits of investigative cases
• Promotes and contributes to a positive, problem-solving environment
• Complies with company policies and procedures andmaintains confidentiality of customer medical records in accordance with stateand federal laws
• Participates in meetings, training and in-serviceeducation, as required
• Performs other duties as assigned

SUPERVISORYRESPONSIBILITY

No

QUALIFICATIONS & EDUCATION

Toperform this job successfully, an individual must be able to perform eachessential duty satisfactorily. The requirements listed below are representativeof the knowledge, skill, and/or ability required. Reasonable accommodations maybe made to enable individuals with disabilities to perform the essentialfunctions.

• Holdone or more designations as an Accredited Healthcare Fraud Investigator (AHFI),Certified Fraud Examiner (CFE), Certified Professional Code (CPC), or PharmacyTechnician, preferred
• Knowledgeof the Fraud and Abuse Health Insurance Industry or Investigative Background
• Strongknowledge and experience in Health Insurance terminology as it relates to FWAdetection, prevention, and correction techniques
• Previousexperience with investigative report writing, interviewing, strategizing andquestion formulation, and presentation skills
• Preferredbut not required, graduate of an accredited college or university with at leasta Bachelor’s degree in Public Health Administration or related field and three(3) years experience working with health insurance claims and complianceauditing; or equivalent combination of education and experience
• Previousexperience in a demanding and/or fast paced setting requiring the ability toprioritize and maintain a heavy case load
• Excellentcomputer knowledge is required, including proficient knowledge of MicrosoftOffice.
• Excellentlistening, interpersonal, verbal and written communication skills withindividuals at all levels of the organization
• Abilityto handle multiple functions and prioritize appropriately
• Abilityto meet strict deadlines
• Abilityto work effectively independently and in a team environment
• Abilityto define problems, collect data, establish facts, and draw valid conclusions
• Must be self-motivated, organized and have excellentprioritization skills
• Mustbe able to work well under stressful conditions
• Fluencyin English required
• Bilingualpreferred, but not required

Posted 30+ days ago

Pre-Credentialing Specialist

Location

Lake Worth, FL

Job Type

Full-time

DUTIES AND RESPONSIBILITIES:

• Furnishes workers with clerical supplies.
• Opens, sorts, and distributes incoming mail, and collects, seals, and stamps outgoing mail.
• Delivers oral or written messages.
• Collects and distributes paperwork, such as records or timecards, from one department to another.
• Marks, tabulates, and files articles and records.
• Operates office equipment such as envelope-sealing machine, letter opener, record shaver, stamping machine, transcribing machine, photocopying machine, and typewriter.
• Delivers items to other business establishments.
• Performs other related duties as assigned by management.

QUALIFICATIONS:

• High school diploma or general education degree (GED); or one to three months related experience and/or training; or equivalent combination of education and experience.
• Strong written, verbal, and interpersonal communications skills including ability to listen attentively and to communicate information clearly and effectively
• Demonstrated interpersonal, collaborative, and relationship-building skills; ability to interact positively with teammates at various levels across the company and customers
• Demonstrated ability to work well with cross-functional groups
• Have a positive attitude and keep a solution-based and customer-focused mindset at all times.
• Take pride in quality of work and attention to detail.
• Professional in-person and phone presence and etiquette.

Posted 30+ days ago