Role: Fraud Investigator
Location: 100% Remote Ideally in Boston, MA but can look regionally and nationwide if need be.
Job Overview:
The Investigator will be assigned to conduct pre-payment reviews of medical records for healthcare claims in one or more of the following areas: (1) Partial Hospitalization and Intensive Outpatient Programs; (2) Laboratory Testing; and/or (3) Durable Medical Equipment. The Investigator will work under the direction of an experienced pre-payment review investigator and work closely with other members of the SIU. Reviews are fast-paced and require the investigator to be organized and efficient in requesting records, reviewing documents, recommending outcomes, and coordinating claim dispositions (payment or denial) within the SIU and with internal business partners.
The Investigator will be responsible for the following:
Drafting and issuing letters to providers requesting clinical records and other relevant documentation
Utilizing case management systems to document case work, including correspondence, findings, and an investigative chronology
Evaluating claims by applying Plan policies and procedures and generally accepted industry standards of practice.
Preparing written summaries of findings, supported by evidence collected in the investigation
Assisting in the preparing fraud referrals to other SIU investigative staff, regulatory agencies, and law enforcement, when appropriate
Contacting members, providers, and other relevant parties to obtain additional information about assigned reviews
Qualifications:
1-3 year's related experience in health insurance fraud investigations, health insurance coding, provider relations, or another similar role
Bachelor's degree
Certified Fraud Examiner (CFE), Certified Professional Coder (CPC), or Accredited Health Care Fraud Investigator (AHFI) preferred
Familiarity with Partial Hospitalization and Intensive Outpatient Programs, Laboratory Testing, and/or Durable Medical Equipment preferred
Skills:
Demonstrated proficiency in Microsoft Word and Excel (including use of analytical tools such as Pivot Tables)
Organization and time-management skills
...MS Word, Excel, PowerPoint Ability to effectively multitask while analyzing and solving problems Thorough understanding of engineering, architectural, and other construction drawings Must be able to traverse and inspect all areas of jobsite in all types of weather...
We Are Seeking Experienced Sales Professionals to Join Our Team!Product &Field of Sales:Highly Dispersible Silica,Conventional... ...regulatory issues.Qualifications:BS/BA degree required; chemical engineering, polymer science background preferred.Minimum 5years...
Gallery Administrative Assistant Location Plymouth, MN : Cambria has an excellent opportunity for a motivated, organized individual seeking a challenging and rewarding opportunity in a fast-paced environment. This position will support day to day operations of the Cambria...
...seeking a highly motivated and ambitious Junior Financial Advisor with a strong... ...delivering exceptional client service and developing customized financial solutions tailored... ...pathway to acquire the essential skills and experience needed to transition into a full-fledged...
We are looking for a Virtual Assistant to provide administrative support to our team while working remotely. As a Virtual Assistant, you will perform various administrative tasks, including answering emails, scheduling meetings and making travel arrangements. For this...