Senior Special Investigation Unit Investigator (Remote in Ohio)
Envolve Pharmacy Solutions
2021-10-27T23:57:36Z
Scientific Research
(No Timezone Provided)
Position Purpose:
Investigate allegations of healthcare fraud and abuse activity. Assist in planning, organizing, and executing special claims investigations or audits that identify, evaluate and measure potential healthcare fraud.
Assist in monitoring business processes and systems to assure integrity and compliance in billing and claims payment Investigate possible waste , abuse and fraud leads and document activity on each lead and refer issues to the appropriate party Develop internal reports to identify potential waste, abuse and fraud Perform data mining and analysis to detect aberrancies and outliers in claims Serve as point of contact for corporate and field inquiries regarding waste, abuse and fraud Review post-payment cases with appropriate parties to obtain refund Provide case updates on progress of investigations and coordinate with Health Plans on recommendations and further actions and/or resolutions Prepare summary and detailed reports on investigative findings for referral to Federal and State agencies Arrange, conduct, and attend meetings with providers, business partners, and representatives from regulatory agencies and law enforcement regarding investigations For Kentucky plan only: Responsible for coordination of the Kentucky Program integrity unit Investigate and oversee cases of healthcare fraud and abuse within Special Investigations Unit (SIU) In addition to coordinating oversight of the program integrity unit, assume responsibility for higher profile and more complex cases Proactively identify trends and aberrant activity to generate leads for fraud investigations and analyze claims data to detect fraudulent activity Prepare cases for referral to law enforcement officials for prosecution Serve as a resource, trainer and mentor to other Special Investigations Unit staf
Education/Experience:
A minimum of two years in a health care field working on fraud, waste, and abuse investigations and audits
A bachelor's degree, or an associate's degree with an additional two years working on health care fraud, waste, and abuse investigations and audits
Ability to understand and analyze healthare claims and coding
Knowledge of Microsoft Applications medical coding, claims processing, and data mining preferred.
Senior Special Investigation Unit Investigator (Remote in Ohio)
Envolve Pharmacy Solutions
Position Purpose:
Investigate allegations of healthcare fraud and abuse activity. Assist in planning, organizing, and executing special claims investigations or audits that identify, evaluate and measure potential healthcare fraud.
Assist in monitoring business processes and systems to assure integrity and compliance in billing and claims payment Investigate possible waste , abuse and fraud leads and document activity on each lead and refer issues to the appropriate party Develop internal reports to identify potential waste, abuse and fraud Perform data mining and analysis to detect aberrancies and outliers in claims Serve as point of contact for corporate and field inquiries regarding waste, abuse and fraud Review post-payment cases with appropriate parties to obtain refund Provide case updates on progress of investigations and coordinate with Health Plans on recommendations and further actions and/or resolutions Prepare summary and detailed reports on investigative findings for referral to Federal and State agencies Arrange, conduct, and attend meetings with providers, business partners, and representatives from regulatory agencies and law enforcement regarding investigations For Kentucky plan only: Responsible for coordination of the Kentucky Program integrity unit Investigate and oversee cases of healthcare fraud and abuse within Special Investigations Unit (SIU) In addition to coordinating oversight of the program integrity unit, assume responsibility for higher profile and more complex cases Proactively identify trends and aberrant activity to generate leads for fraud investigations and analyze claims data to detect fraudulent activity Prepare cases for referral to law enforcement officials for prosecution Serve as a resource, trainer and mentor to other Special Investigations Unit staf
Education/Experience:
A minimum of two years in a health care field working on fraud, waste, and abuse investigations and audits
A bachelor's degree, or an associate's degree with an additional two years working on health care fraud, waste, and abuse investigations and audits
Ability to understand and analyze healthare claims and coding
Knowledge of Microsoft Applications medical coding, claims processing, and data mining preferred.