Principal Medical Review Auditor
6 days left
- Full Time
As a trusted systems integrator for more than 50 years, General Dynamics Information Technology provides information technology (IT), systems engineering, professional services and simulation and training to customers in the defense, federal civilian government, health, homeland security, intelligence, state and local government and commercial sectors. Analyzes user needs and performs research and functional analysis on a variety of projects.
- Conducts audits of medical records and healthcare claims in support of fraud, waste and abuse investigations or for other program integrity initiatives.
- Prepares and submits reports on results of medical audits with recommendations to investigative staff and/or customers including but not limited to denial and/or recovery of overpaid claims as a result of fraud, waste, and abuse, process improvements, and educational opportunities for the subjects under review.
- Conducts medical policy and other relevant research in support of investigations.
- Uses knowledge of healthcare coding conventions, medical policies, fraud schemes, areas of vulnerability, reimbursement methodologies, and relevant laws to detect and investigate suspicious patterns in claims data, provider enrollment data, and other sources.
- Maintains current knowledge of relevant regulations and standards, including, but not limited to, federal and state policies and coding guidelines.
- Conducts investigation-related training.
- Prepares and conducts provider education through written reports and in-person or telephonic meetings.
- Supports legal proceedings as needed, including testifying in court or working with law enforcement personnel to prepare cases for civil or criminal actions.
- Analyzes user needs to determine functional requirements for a wide variety of projects.
- Performs technical assessments aimed at improving client systems.
- Performs functional allocations to identify tasks and their inter-relationships.
- Researches, identifies, and recommends resources required for task execution and completion.
- Performs functional modeling based on requirements analysis.
- Develops new systems or updates existing systems to meet client needs.
- Serves as technical advisor to clients in assigned subject areas, recommends functional changes, and identifies areas for further investigation.
- Generates recommendations in the form of technical briefings, reports, and other major documents provided to senior level client personnel.
- Consults with clients to determine optimum design for assigned projects.
- Identifies emerging relevant technologies that may result in improvements to current processes and systems.
- Writes and updates project documentation including system procedures, presentations, and training materials.
- Conducts functional testing of various systems.
- Provides guidance and work leadership to less-experienced analysts, and may have supervisory responsibilities.
- May serve as technical team or task lead.
- Maintains current knowledge of relevant technologies and subject areas.
- Participates in special projects as required.