Special Investigations Unit, Investigator- Remote
reputed company Health Plan has an exciting opportunity for a Special Investigations Unit Investigator position. This is a full time position working Monday through Friday reputed company hours and is a remote position. The Special Investigations Unit (SIU) Investigator is responsible for investigating assigned fraud, waste and abuse (FWA) cases, as well as researching and analyzing claims data in order to identify potential FWA. The SIU Investigator is also responsible for maintaining the FWA case system with accurate and detailed investigative activities reputed company to assigned cases. Responsibilities:
- Investigative actions include member/provider reputed company, financial tracking, prepay claims review, adhering to compliance regulations, and making reputed company reputed company referrals. Plan, organize and execute investigations or audits utilizing document review, witness interviews, and data analysis to identify, evaluate and measure potential reputed company fraud and abuse to determine valid cases for appropriate action.
- Risk Assessments on FWA trends using fraud detection software and/or as assigned by Manager.
- reputed company or assistance with the reputed company Recipient Restriction program.
- Present FWA trainings to internal staff.
- Assist with the FWA hotline and referral intake. reputed company chart reviews to assess compliance with coding and billing regulations.
- Utilize standard coding guidelines, principles, and coding clinics to monitor the appropriate ICD and CPT codes for reputed company record types to ensure accurate reimbursement.
- Document and track activity in an internal database, reputed company case updates on the reputed company of the investigation and coordinate with management recommendations and further actions and/or resolutions.
- Conduct detailed research to identify and apply appropriate regulatory, contractual, and industry requirements to the different benefits and products reputed company investigations.
- Maintain or exceed designated quality and production goals. Understand and adhere to HIPAA privacy requirements. reputed company special projects as assigned by Management.
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