Role Description

Under the guidance of the SIU Management, this position is responsible for the accurate and thorough clinical investigation of potential fraud, waste and abuse (FWA) for all lines of business. The scope of accountability includes investigating and remediating allegations of FWA while adhering to compliance and regulatory requirements.

• Functions as a clinical reviewer of medical records, researching and investigating complex medical cases.
• Interprets a variety of documents including provider contracts, group benefit structures, Corporate Medical Policies, AMA CPT Coding Guidelines, HCPCS coding, inter-plan regulations, and government policies.
• Thoroughly researches allegations or issues and develops sources of information to create a plan of action.
• Accumulates sufficient detailed evidence including statements, documents, records, and exhibits.
• Evaluates situations accurately and interacts with management, medical directors, and legal, where appropriate.
• Prepares comprehensive summary reports and assures accuracy of information provided to providers, regulators, law enforcement, Legal, Compliance, and outside counsel.
• Prepares cases for prosecution, civil settlement, or overpayment recoupment by documenting findings clearly.
• Analyzes proactive detection reports and claims data to identify red flags/aberrant billing patterns.
• Manages cases as assigned, prioritizing case load as appropriate.
• Maintains case logs, prepares records, and regular status reports.
• Interacts with health care providers under adverse conditions due to potential FWA discovery.
• Discusses sensitive material in a professional, fair, and accurate manner.
• Recommends providers for referrals to the New York State Office of Professional Medical Conduct/NYS Education Department.
• Acts as primary point of contact with law enforcement for assigned cases.
• Prepares recommendations on preventive/corrective measures for future fraud deterrence.
• Supports other SIU investigators and analysts with their cases.
• Consults with external practitioners, medical professional groups, and agencies.
• Maintains accurate and up-to-date knowledge of all Government Programs regulations.
• Demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies’ mission and values.
• Maintains high regard for member privacy in accordance with corporate policies.
• Regular and reliable attendance is expected and required.
• Performs other functions as assigned by management.

Qualifications

• Must meet the NYS DFS’s and the NYS OMIG’s minimum investigator requirements.
• A minimum of five years in the healthcare field working in FWA investigations and audits; or five years of insurance claims investigation experience; or seven years of professional investigation experience involving economic or insurance-related matters.
• Current NYS R.N. license with a minimum of three years clinical experience; medical/surgical background preferred.
• Current CPC designation or must obtain CPC designation within one year of hire date.
• Knowledge of medical record coding conventions (e.g. CPT, DRG, HCPCS, ICD10, etc.).
• Demonstrates excellent oral communication skills and proficient writing skills.
• Demonstrates proficient computer skills in Word, Excel, Internet, and email.
• Ability to multi-task and balance priorities.
• Excellent interpersonal skills.

Requirements

• Two or more years of experience in the Medical Investigator role (Level II).
• Five or more years in a Medical Investigator role (Level III).
• Expertise in the technology of the job.
• Excellent understanding of contract benefits and corporate policies.
• Excellent dispute resolution and negotiation skills.
• Demonstrated superior oral communication skills and strong presentation skills.
• Proficient with health systems operations and understanding of reimbursement methodologies.
• Extensive experience with claims processing systems and claims flow.

Benefits

• Participation in group health and/or dental insurance.
• Retirement plan.
• Wellness program.
• Paid time away from work.
• Paid holidays.

Compensation Range(s)

• Level I (E2): Minimum: $62,400 - Maximum: $96,081
• Level II (E4): Minimum: $65,346 - Maximum: $106,929