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Role Description

Serves as an entry level professional who develops baseline plans for ensuring the integrity and accuracy of claims processes and protocols. Collects data for audits/investigations into claims, utilizing a combination of analytical skills and attention to detail, reviewing documentation, interviewing involved parties, and communicating with various stakeholders to gather relevant information for successful resolution and closure. Identifies opportunities to target fraud, waste, and abuse or discrepancies in claims submissions. Adheres to industry regulations and company policies for managerial follow-up. Analyzes data in order to effectively assess the validity of claims. Provides accurate recommendations to management for claim resolution and closure. Documents and inputs all findings, while preparing comprehensive reports that may be used for legal or audit/investigative purposes.

Essential Duties and Responsibilities

• Conducts routine and impartial audits/investigations into customer claims, ensuring accurate and fair assessments of claims validity.
• Provides customer service by addressing inquiries and concerns, and escalates audit/investigation, as needed.
• Compiles detailed and organized records of audit/investigation findings, ensuring accuracy and compliance with legal and regulatory requirements.
• Applies functional knowledge to create and implement strategies to identify and prevent fraudulent activities, safeguarding the integrity of the claims process.
• Conducts interviews with relevant witnesses, claimants, and other stakeholders to gather additional information and perspectives on claims.
• Communicates with appropriate internal teams to ensure the proper processing of audits/investigations, while adhering to legal and regulatory standards.
• Ensures that all audit and investigative documents and records are processed into the database in a timely and accurate manner.
• Communicates audit/investigation findings clearly and professionally to customers, claimants, and other stakeholders, managing expectations and providing updates.
• Supports management in regular audit and investigation proceedings, ensuring full compliance with all applicable regional and federal standards, regulations, and protocols.

Qualifications

• Minimum Bachelor's Degree
• Prior experience in healthcare fraud investigation

Preferred Skills/Experience

• Certified Fraud Examiner or Accredited Healthcare Anti-Fraud Investigator
• Prior successful experience with CMS and OIG/FBI or similar agencies
• Medicare investigation experience a plus