PRINCIPAL ACCOUNTABILITIES: Under the direction of the assigned SI Supervisor or Manager, functions include but are not limited to:
Review of medical records and claims
a. Investigate potential fraud and over-utilization by performing complex medical reviews of claims and medical records. The claims may be in a pre or postpayment environment..
b. Provide a detailed but concise analysis to communicate findings about the ability to pay or deny a claim or claim lines using clinical and/or coding, billing, or reimbursement knowledge.
c. Maintain appropriate records and supporting documentation regarding findings in accordance with departmental standards.
d. Process all assigned claims or batch case reviews within departmental and communicated timelines.
Provide support to investigative teams as they perform all levels of healthcare fraud, waste, and abuse investigations. Oral, written, and other communication skills are used to effectively accomplish the various tasks associated with case investigations including the ability to communicate technical clinical information to non-clinical individuals. Collaborate with investigative teams to correlate review findings with appropriate actions (e.g., provider education through original, complex, and technical letters, meeting and negotiating with providers, recoveries of monies, recommending network de-selection referrals to State and/or Federal Agencies to effect changes in the provider’s/facility’s practice.
When assigned act as liaison/consultant inside corporation on cases, in cooperation with areas such as Medical Policy, Legal and Legislative Affairs, Claims Processing Areas, Customer Service Operations, Provider Representatives, Credentialing, Contracting, Appeals and Grievances, and Utilization Management. This may include nNotification to above areas of problem providers/facilities, recommending changes to system edits, requesting modifications to medical policy and respective changes to on-line policy edits, and educating the above areas regarding appropriate claims processing for a particular provider/facility or service.
When assigned acts as liaison/consultant to agencies outside the corporation, developing cases in cooperation with Boards of Medicine, local medical societies, and State and/or Federal agencies including Office of the Inspector General, Office of Personnel Management, and Federal Bureau of Investigations. Assists outside agencies by gathering data and medical documentation for subpoenas, responds to attorney inquires and requests, and testifies in State and/or Federal courts when required. Investigates and resolves individual member inquiries and complaints related to over-utilization or potential fraud by health care providers/facilities.
Perform special projects to meet the objectives of the Special Investigations Unit.
Required: BS/BA degree or its equivalent in nursing and at least 5 years of nursing experience. Active RN license.