This opportunity is open to remote applicants in the United States, with the exception of the following states:
Washington, Wyoming, North Dakota, and Ohio.
The SIU Investigator supports the compliance related activities of the Program Integrity Department. Responsible for conducting proficient reviews into suspected fraud, waste, or abuse with respect to provider, pharmacy, employer, member, and broker interactions involving the full range of products at Presbyterian. This includes the identification, investigation, and correction of fraudulent, wasteful, and/or abusive billing and coding practices; coordination of recovery of overpayments related to fraudulent and/or abusive billing and coding practices; and providing education related to coding/representation of services and appropriate medical record documentation requirements. The ideal candidate should have proficient experience in claims fraud, waste and abuse investigation.
* Associates degree and 3 years related experience required. 3 years of additional experience can be substituted in lieu of degree.
* CPC or equivalent required
* Certified Fraud Examiner (CFE) or Accredited Health Care Fraud Investigator (AHFI) preferred
Proficient level of:
* Investigational experience
* Procedural coding
* Technical writing skills
* Analytical skills
* Ability to learn
* Critical thinking and attention to detail
* Facilitating meetings
* Authoring articles & letter members & providers
* Engaging with all levels of staff and management within the organization, committee members, leadership, as well as the public
* Demonstrated ability to communicate effectively in person and via telephone with members, employer groups, physicians, and physician office staff using strong dialogue and customer service competencies
* Resolving conflicts
* Negotiating with vendors
Intermediate level of:
* Compliance with specifics to Healthcare accreditation and CMS.
* Managed Care and awareness enterprise operations, functions & processes.
* MS Office
* Adobe Pro
* In collaboration with Senior Investigator and Manager, manages the overall direction, coordination, implementation, execution, and completion of assigned investigations ensuring consistency with department strategy, commitments, and goals.
* May be responsible for concurrent and/or retrospective review, data abstraction, analysis, identification of critical issues, process improvement support, required education, and assisting with measurement of performance metrics.
* Serves as resource recommending process modifications and practice changes to improve efficiency, effectiveness, and reliability of processes and systems.
* Builds and develops collaborative relationships vital to the success of cases and department.
* Conducts advanced fraud, waste and abuse audits in accordance with compliance and audit work-plan and prepare detailed audit reports for management, legal counsel, and providers.
* Identifies, investigates, and resolves billing and coding related inquiries and complaints from beneficiaries, members, regulatory agencies and internal and external customers through recoupment of overpayments and education to providers