Senior SIU Analyst

Columbia MD 21046 6950 Columbia Gateway Drive

Job Description

Responsible for comprehensive management, ownership and timely completion of desk audits and investigations with a medium to high priority and complexity. carries out analytical and process management task with a high degree of autonomy. Serves as a SME for preliminary investigations, a corporate resource on fraud, waste and abuse issues, and recommends cost containment projects with an emphasis on fraud prevention.

FRAUD, WASTE AND ABUSE DETECTION
• Prioritize and manage workload to meet internal performance metrics, regulatory and contractual requirements
• Use independent judgment to plan and conduct desk audits and investigations based upon analysis of referral data and contractual/regulatory requirements
• Conduct provider and member interviews as a part of the overall review process
• Use data mining techniques to identify suspicious patterns and outliers in claims data
• Complete root cause analysis to support the department’s efforts in FWA prevention and detection
• Track and respond to RIAs (Request for Investigative Assistance)

• PACKAGING OF FINDINGS AND RECOMMENDATIONS
• Organize data and prepare a detailed finding report with summary of investigative steps, conclusions, recommendations with attention to detail and a high level of accuracy
• Clearly and concisely present findings to management, customers and internal and external departments

• MISCELLANEOUS DUTIES
• Provide feedback, guidance and training to staff regarding strategy, analysis, recommendations and other related tasks
• Provide backup support to Lead Analyst in the performance of job duties as assigned
• Actively participate in special projects, case information sharing
• Successfully complete required trainings and continuing education credits
• Other duties as assigned

Required Qualifications:
• Proven ability to effectively handle cases of fraud and abuse in a discreet, confidential, and professional manner
• Experience with managed health care business model and processes, preferably in behavioral health, radiology or pharmacy
• Demonstrated strategic and analytical thinking skills, with ability to effectively communicate conclusions and recommendations to a broad audience
• Strong understanding of insurance terms, CPT/Revenue/HCPCS codes with ability to research and interpret language related to regulations, policies and contracts
• Demonstrated skills with Microsoft Office products, with emphasis on in creating pivot tables, charts and graphs, formulas, conditional formatting and other advanced features in Excel

General Job Information

Title

Senior SIU Analyst

Grade

19

Job Family

Finance Group

Country

United States of America

FLSA Status

United States of America (Non-Exempt)

Recruiting Start Date

8/21/2019

Date Requisition Created

8/21/2019

Work Experience

Fraud Investigations

Education

GED (Required), High School (Required)

License and Certifications - Required

License and Certifications - Preferred

CFE - Certified Fraud Examiner - Enterprise

Other Job Requirements

Responsibilities

Minimum of 5 years fraud investigations, claims processing, auditing or provider networks at expert level.- Knowledge of group health or managed care claims payment processes preferably in behavioral health.-Proven ability to effectively handle cases of fraud and abuse in a discreet, confidential, and professional manner-Demonstrated strategic and analytical thinking skills, with ability to effectively communicate conclusions and recommendations to management-Understanding of insurance terms and policy interpretation-Intermediate to high computer skills consisting of Microsoft Excel, Access, Outlook, Word and Power Point.

Magellan Health Services is proud to be an Equal Opportunity Employer and a Tobacco-free workplace. EOE/M/F/Vet/Disabled. Every employee must understand, comply and attest to the security responsibilities and security controls unique to their position.

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