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
...thinker who can proactively prevent, detect, and resolve complex fraud schemes while ensuring our systems and processes meet the... ...transactions. Responsibilities: Lead and conduct in-depth investigations into suspected payment card fraud and other financial crimes,...
...Location: NorCal, Remote but must be commutable to Cupertino Experience: 7+ years 1 Year Contract Were looking for a highly... ...design at scale Working across Wrike, Quip, Box, and Miro to manage systems and documentation What were looking for: ~5+...
...collaborative environment. Yelp is seeking an entry-level Software Engineer who is excited to work... .... In this role, you'll help design and develop systems that power Yelps advertising... ...150 monthly reimbursement to help cover remote working expenses. ~95 caregiver...
...Job Description LanceSoft is seeking a travel Sterile Processing Technician for a travel job in Bethpage, New York. Job Description & Requirements... ...High School Diploma or equivalent, required 1.5+ years experience accepted if tertiary experience; 2+ years experience if...
...Job Description Job Description Salary: $47k - $57k (DOE), plus commission Business Development Representative - Plumber sales All of Apex DKI hiring is conducted through Accentuin. If you are selected for review, you will recieve correspondence from Accentuin...