Job Description

Job Description

Job Description

POSITION SUMMARY

This position will investigate allegations of potential healthcare fraud and abuse activity. Assist in planning, organizing, and executing claims investigations or audits that identify, evaluate and measure potential healthcare fraud and abuse

ESSENTIAL DUTIES & RESPONSIBILITIES

• Conduct investigations of potential waste, abuse, and fraud
• Document activity on each case and refer issues to the appropriate party.
• Perform data mining and analysis to detect aberrancies and outliers in claims.
• Develop new queries and reports to detect potential waste, abuse, and fraud.
• Provide case updates on progress of investigations and coordinate with Health Plans on recommendations and further actions and/or resolutions.
• Assist with complex allegations of healthcare fraud.
• Prepare summary and/or detailed reports on investigative findings for referral to Federal and State agencies.
• Complete various special projects and audits
• Interpret and analyze new HPMS memoranda, alerts, and regulatory guidance to assess the impact on Fraud, Waste, and Abuse (FWA) programs.

QUALIFICATIONS & EDUCATION

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required.

Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

• Bachelor’s degree in business, Criminal Justice, Healthcare, related field or equivalent experience.
• 1+ years of medical claim investigation, medical claim audit, medical claim analysis, or fraud investigation experience.
• Knowledge of medical coding and terminology.
• Advanced Proficiency in Microsoft Excel, Data Analysis and Fraud Detection.
• Advanced skills in SQL, SAS and business intelligence (BI) tools are preferred

WORK CONDITIONS

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

• The noise level in the work environment is usually moderate.
• Fast-paced office environment.
• Highly regulated environment.
• Time frames to handle issues are in accordance with CMS and NCQA as well as internal time frames.
• Interacts with providers, staff, visitors, government agencies, etc., under a variety of conditions and circumstances.

This work requires the following physical activities: climbing, bending, stooping, kneeling, twisting, reaching, sitting, standing, walking, lifting, finger dexterity, grasping, repetitive motions, talking, hearing and visual acuity. The work is performed indoors. Sits, stands, bends, lift, and moves intermittently during working hours.

PHYSICAL DEMANDS

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

The employee must be able to frequently lift up to 10 pounds and occasionally lift and/or move up to 25 pounds. While performing the duties of this job, the employee is regularly required to talk or hear. The employee is frequently required to stand and walk. The employee is occasionally required to use hands to finger, handle, or feel; reach with hands and arms; climb or balance and stoop, kneel, crouch, or crawl. Specific vision abilities required for this job include close vision, distance vision, color vision, peripheral vision, depth perception, and the ability to adjust focus.

PERFORMANCE MEASUREMENTS

• 3-5 Monthly evaluations
• Compliance with Department Call Metrics/ Company Regulations
• Attendance/Punctuality
• Safety and Security
• Quality of work

This Job Description may be modified at any time at the discretion of the employer as business operation may seem necessary. This does not constitute an employment agreement and may not include all duties. The above statements are intended to describe the general nature and level of work being performed by individuals assigned to this position. They are not intended to be an exhaustive list of all duties, responsibilities, and skills required of personnel so classified. The incumbent must be able to work in a fast-paced environment with a demonstrated ability to juggle and prioritize multiple competing tasks and demands and to seek supervisory assistance as appropriate.

Solis Health Plans provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state, or local laws.

This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation, and training.

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