What are the responsibilities and job description for the Special Investigation Unit Analyst Health Plan position at Corewell Health?
Performs activities to support a prepayment review program. Reviewing medical record documents for verification of code assignment in accordance with official coding guidelines and health plan policies. Position requires experience in coding across multiple provider specialties, auditing experience preferred. Performs activities related to the detection and investigation of fraud and abuse within Priority Health. Assists with internal and external education on fraud, waste, abuse, billing and documentations requirements.
Responsible for investigating, collecting, researching data in order to detect fraudulent or abusive practices by utilizing system tools, interviews, medical records audits, data mining, perform compliance audits of medical claims, fee screens and other payment mechanism to ensure accurate payment.
- Investigate fraud and abuse tips received through the compliance hotline, internal referral or identify through data analytics. Support information requests my government agencies, law enforcement, external auditors, etc. Conduct telephone and in person interviews which may include members, providers, employer group agents etc. to determine validity of allegations of fraud waste and abuse. May include conversations with law enforcement and regulatory agencies.
- Prepare financial analyses and reports to document finding and maintain up to date case files. Case files to include documentation to substantiate investigative process, findings, final report. In addition, notifications of finding letter for dissemination to provider or affected entity, notification letters to regulatory agencies if applicable. Presents provider offers for settlement to management and legal for approval.
- Responsible for understanding plan documents, provider and agent agreements, products offered, State and Federal laws related to fraud, waste or abuse, Medicare and Medicaid regulations, etc.
- Ability to work effectively with minimal supervision and direction and exhibit good problem solving skills.
- Assists in training of fraud awareness for members, providers, employer groups, agents and vendors.
- Required Bachelor's Degree or equivalent Health, Business or statistics
- 2 years of relevant experience Detection, prevention and recovery related to abusive and fraudulent practices related to hospital, physician, pharmacist pharmacy, employer group, agent or other fraudulent entity. Required
- 2 years of relevant experience Related health care experience Required
- CRT-Professional Coder - AAPC American Academy of Professional Coders
- CRT-Coding Specialist, Certified-Physician Based (CCS-P) - AHIMA American Health Information Management Association
- Facets experience preferred
- Strong written and verbal skills preferred
- Excel experience preferred
Primary Location
SITE - Priority Health - 1231 E Beltline - Grand RapidsDepartment Name
PH - Special Investigations UnitEmployment Type
Full timeShift
Day (United States of America)Weekly Scheduled Hours
40Hours of Work
8 a.m. to 5 p.m.Days Worked
Monday to FridayWeekend Frequency
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Corewell Health is committed to providing a safe environment for our team members, patients, visitors, and community. We require a drug-free workplace and require team members to comply with the MMR, Varicella, Tdap, and Influenza vaccine requirement if in an on-site or hybrid workplace category. We are committed to supporting prospective team members who require reasonable accommodations to participate in the job application process, to perform the essential functions of a job, or to enjoy equal benefits and privileges of employment due to a disability, pregnancy, or sincerely held religious belief.
Corewell Health grants equal employment opportunity to all qualified persons without regard to race, color, national origin, sex, disability, age, religion, genetic information, marital status, height, weight, gender, pregnancy, sexual orientation, gender identity or expression, veteran status, or any other legally protected category.
An interconnected, collaborative culture where all are encouraged to bring their whole selves to work, is vital to the health of our organization. As a health system, we advocate for equity as we care for our patients, our communities, and each other. From workshops that develop cultural intelligence, to our inclusion resource groups for people to find community and empowerment at work, we are dedicated to ongoing resources that advance our values of diversity, equity, and inclusion in all that we do. We invite those that share in our commitment to join our team.
You may request assistance in completing the application process by calling 616.486.7447.
