Healthcare Claims Investigator

Location: Orange, CA
Date Posted: 03-01-2018
Claims Investigator – Managed Care
Orange, CA
*** This is a Full-Time, Benefits Available, CONTRACT assignment, expected to last around 2-3 months, or longer! ***

Claims Investigator Job Summary: 
  • The Claims Investigator will collaborate with all internal departments across the organization to prevent, detect, investigate and report potential cases of fraud, waste and abuse.
  • This position will conduct accurate data analysis, interview members and/or providers, conduct onsite and desk audits, calculate overpayments, collect overpayments, package cases for referral to law enforcement, identify health plan vulnerabilities, develop and deliver provider education programs, and consult on anti-fraud policies and procedures.
  • Assist Special Investigations Unit (SIU) Investigators with properly identifying abnormal billing patterns through utilization reviews and data analysis.
  • Triages and prioritizes leads from external sources, including fraud detection software.
  • Assist in identifying fraudulent providers, potential fraud schemes and policy gaps affecting the primary functions of the Compliance department.
  • Manage special projects related to claims payment review as they arise (e.g., running special reports or contacting providers and beneficiaries, developing provider feedback or provider report cards).
Claims Investigator Background: 
  • Requires an education level of at least a high school diploma or GED; Associate’s or Bachelor’s degree is a plus.
  • Other certifications considered a plus: Certified Coding Specialist (CCS), Certified Fraud Specialist (CFS), Accredited Healthcare Fraud Investigator (AHFI), and Certified Fraud Examiner (CFE).
  • 3 years’ experience reviewing & auditing medical records at an acute care facility, a health insurance company, audit review agency, or other related business.
  • Around 5 years' healthcare experience is preferred, ideally in a quality/SIU role for cases of Fraud, Waste or Abuse.
  • Knowledge of medical terminology, CPT, Revenue Codes, ICD-10 and HCPCS codes is a plus.
  • Prior health plan experience or strong working knowledge of State and Federal regulations, including the Centers for Medicare & Medicaid Services, is strongly preferred.
  • Must have experience in claims systems, reviewing claims with associated medical records
  • Strong analytical mind, with problem solving and investigative skills, an aptitude for accuracy, and attention to detail.
  • Experience with FACETS or other billing and accounts receivable or claims payment system.
  • Prior prosecution experience or experience working with FBI, HHS-OIG Assistant U.S. Attorneys, or State Attorneys General helpful.
Associate Search Consultant
CareNational Healthcare Services
480.448.6498 (CALL – TEXT – FAX)
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