What are the responsibilities and job description for the FRAUD INVESTIGATOR position at APWU AFL-CIO HEALTH PLAN?

Job Description

POSITION PURPOSE :

To assist in the special investigations operation and maintenance of a cost-effective fraud and abuse program through internal resources and assistance from outside vendors.

NATURE AND SCOPE :

This position is responsible for coordinating internal and external resources to enhance the detection and deterrence of fraudulent or abusive activities perpetrated against the Health Plan and its members. This is completed through comprehensive in depth review of suspected claims fraud referrals received from outside sources (e.g., providers or members) or, internally, by utilizing investigative guidelines from the Office of Inspector General (OIG) or the National Health Care Antifraud Association to investigate active claims.
The incumbent is responsible for efficiently and accurately assessing referrals submitted for investigation to determine if there is merit in the allegation and a matter that should be addressed. A comprehensive review will be conducted to identify highly suspect billing behaviors and trends, and potential overpayments, ultimately leading to formulation of specific investigative next steps. The finished product should be designed in a manner that allows the investigator to fully understand what actions should be taken to mitigate patient harm and financial risk. Similar action will be taken when suspicion arises by means of internal claims investigation.
The incumbent will utilize technology and analysis to drive the results of major case investigations, and will monitor the progress of the investigation. As new information surfaces, the course of the investigation may be redirected.
This position will coordinate between the Health Plan and external fraud and abuse vendors on non-clinical decision making activities. The incumbent must respond to requests from the Office of the Inspector General in a timely manner. Further, the individual will attend periodic industry and OIG meetings to actively participate in the development and sharing of information.
One of the most important aspects of this position is the necessity to handle personal and confidential information with a high degree of integrity.

PRIMARY ACCOUNTABILITIES :

Research and analyze data for insurance fraud while applying appropriate investigative techniques.

Investigate and handle internal and external fraud and abuse activities.

Identify, prepare and track potential OIG notifications and correspondence.

Conduct interviews and process vendor claims / case investigations.

Contribute ideas for developing system edits and programs to detect fraudulent billing practices on a proactive basis.

Track fraud and abuse inventory and savings reports for internal and external reports.

Update and maintain internal, OIG and Vendor Fraud Waste and Abuse data tracking reports as directed.

Responsible for standing in for the lead investigator when needed and performing other duties as assigned.

Other duties as assigned.

QUALIFICATIONS :

Bachelor’s degree or equivalent work experience.

A minimum of 5 years of experience in healthcare fraud, analytics, medical coding, and the operations of special investigative units (SIU)

One of the following Certifications preferred :

Accredited Healthcare Fraud Investigator (AHFI)

Certified Fraud Investigator

Medical Auditing or Clinical Coding Certifications such as CPC, CEMA, or CPMA

Experience with fraud and abuse software and ability to data mine claims system data.

Ability to define data and information needs; compile, analyze and interpret data relative to healthcare utilization.

Knowledge of medical terminology, CPT and ICD10 coding, investigative techniques, analytical methodologies, and insurance and claim operations.

Multi-disciplinary project management skills.

Highly organized, motivated self-starter with strong analytical and problem solving skills.

Excellent computer skills to include Microsoft Office, Healthcare Fraud Shield software suite, QNXT software suite, savvy internet research skills and Ad hoc query and reporting.

Excellent analytical, verbal and written communication skills.

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FRAUD INVESTIGATOR

What are the responsibilities and job description for the FRAUD INVESTIGATOR position at APWU AFL-CIO HEALTH PLAN?

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