Columbia MD 21046 8621 Robert Fulton Drive
Job DescriptionResponsible for the intake and initial handling of allegations of fraud, waste or abuse. Conducts preliminary investigation to assess the merit of an allegation through fact gathering and analysis of data. Uses independent judgment to conclude preliminary investigation in accordance with procedures or to present to management to recommend for audit or investigation. Serves as a corporate resource on fraud, waste and abuse issues and maintains confidentiality and compliance with HIPAA privacy requirements and applicable state and federal regulations.
FRAUD, WASTE AND ABUSE DETECTION:
- Maintains caseload of incidents with low to medium priority and complexity.
- Prioritize and manage workload to meet internal performance metrics, regulatory and contractual requirements.
- Analyze data to find suspicious patterns and outliers using knowledge of healthcare coding conventions, fraud schemes, and general areas of vulnerability.
- Contact referrer, member, provider, or witnesses to gather additional information, facts and supporting documentation.
- Collaborate and refer non-SIU related issue and activities to external departments (Cost Containment, Networks, Clinical) for handling.
PACKAGING OF FINDINGS AND RECOMMENDATIONS:
- Organize data and document preliminary investigative steps with a high level of detail and accuracy, to clearly and concisely support conclusions and recommendations.
- Provide backup support to team members (SIU Coordinator and Senior SIU Specialist) in the performance of job duties as assigned.
- Successfully complete required training sessions and continuing education credits.
- Other duties as assigned.
General Job Information
Job FamilyFinance Group
CountryUnited States of America
FLSA StatusUnited States of America (Non-Exempt)
Recruiting Start Date9/24/2019
Date Requisition Created9/24/2019
Work ExperienceClaims, Fraud Investigations
License and Certifications - Required
License and Certifications - PreferredCFE - Certified Fraud Examiner - Enterprise
Other Job Requirements
- CFE - Certified Fraud Examiner credential preferred.
- Bachelor’s degree preferred.
- Prefer knowledge of managed health care business model and processes, preferably in behavioral health, radiology or pharmacy.
- 3+ years' fraud investigations/claims experience.
- Ability to manage workload while simultaneously working on multiple projects and cases with timely and accurate results with limited supervision.
- Demonstrated strategic and analytical abilities to review and evaluate information such as claims data, suspicious patterns and other supporting information related to case allegation.
- Requires the verbal, written and interpersonal skills to effectively interact and communicate conclusions and recommendations to management and customers.
- Proficient with Microsoft Office Word, Excel and PowerPoint with ability to quickly learn and use new software applications.
- Knowledge of ICD-9/10, CPT/HCPS/Revenue codes, insurance terms and policy interpretation.
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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