!! FRAUD, INVESTIGATIONS, AUDITING, WASTE AND ABUSE PROFESSIONALS !!

Location
Virginia Beach, VA
Posted
Feb 03, 2017
Closes
Jul 20, 2017
Function
Audit and Tax
Industry
Healthcare
Hours
Full Time
Job Description:
Do you have experience in Fraud Waste and Abuse?
Or Maybe Special Investigations, Regulatory or Compliance?

Optima Health in Virginia Beach, VA is seeking a talented individual skilled in investigating and auditing medical and behavioral health for fraud, abuse and cost containment. The ideal candidate will be experienced in Claims Fraud, Waste and Abuse Investigation; however, this niche role can yield from: nursing, clinical coding, medical coding, claims expertise, external auditing and compliance expertise.
Specific progression of responsibility is as follows dependent upon education, certifications, and experience:

Associate Investigator
  • Triage and prioritize leads/member complaints from internal sources.
  • Review and assess incoming referrals; Assist in the investigation of potential fraud, waste, and abuse.
  • Conduct research in support of an investigation.
  • Collect and evaluate potential suspicious patterns in claims data, provider enrollment data, and other sources and refers to Investigator for investigation or settlement.
  • Assures accurate reimbursement is obtained and coding practices are compliant.
  • Maintain comprehensive case files.
  • Participates in special projects as required.
  • Requires a Bachelor's Degree OR minimum of 2 years related experience (in Medical Coding, Healthcare [Medical Chart Reviews/Insurance Billing], Internal/External Audit, Regulatory/Compliance, Claims Investigations or Criminal Investigations/White Collar Crime)
Investigator
  • Identify, investigate, analyze and evaluate instances of potential fraud, waste, and abuse.
  • Conduct interviews or correspond with patients, providers, witnesses or other relevant parties to determine settlement, denial, or review.
  • Analyze information gathered by investigation and report findings and recommendations as a written summary and/or presentation.
  • Learn and conduct statistical sampling of complex medical claims.
  • Assists in drafting settlements.
  • Requires a Bachelor's Degree AND minimum of 2years related experience (in Medical Coding, Healthcare [Medical Chart Reviews/Insurance Billing], Internal/External Audit, Regulatory/Compliance, Claims Investigations OR Criminal Investigations/White Collar Crime)
Senior Investigator
  • Conducts investigation-related training.
  • Negotiates settlement agreements to resolve disputes.
  • Maintain current knowledge of relevant laws, regulations and standards.
  • Updates department policies and procedures and assists in training staff on changes.
  • Prepares routine department reporting as needed.
  • Requires a Bachelor's Degree AND minimum of 5 years related experience (in Medical Coding, Healthcare [Medical Chart Reviews/Insurance Billing], Internal/External Audit, Regulatory/Compliance, Claims Investigations OR Criminal Investigations/White Collar Crime)
  • Certified Fraud Examiner (CFE) OR Accredited Health Care Fraud Investigator (AHFI) required.

Principal Investigator
  • Assist manager in development and conducting division wide Fraud, Waste and Abuse related training.
  • Develops and updates department policies and procedures and trains staff as needed.
  • Develops and prepares departmental reporting for internal and external use.
  • Assist manager in implantation and compliance with of state and federal program integrity activities and reporting requirements.
  • Supports legal proceedings as needed, including testifying in court or working with law enforcement personnel to prepare cases for civil or criminal actions.
  • Assist in training and provides guidance to less experienced investigative staff.
  • Requires a Bachelor's Degree AND minimum of 8 years related experience (in Medical Coding, Healthcare [Medical Chart Reviews/Insurance Billing], Internal/External Audit, Regulatory/Compliance, Claims Investigations OR Criminal Investigations/White Collar Crime)
  • Certified Fraud Examiner (CFE) OR Accredited Health Care Fraud Investigator (AHFI) required.

Responsible for leading the SIU efforts, providing oversight and guidance to the team. Conducting in-depth investigations for suspected fraud or abuse with respect to provider, pharmacy, employer, member, and broker interactions involving the full range of products at Optima Health.

Education Level
Bachelor's Level Degree

Experience
Minimum 3 years of related experience.

License
Required: None, unless noted in the “Other” section below

Preferred: Cert Professional Coder

Skills
None, unless noted in the “Other” section below

Other
Bachelors degree required and CPC required within 12 months of hire. Certified Fraud Examiner (CFE) or Accredited Health Care Fraud Investigator (AHFI) preferred.