What are the responsibilities and job description for the Fraud Investigator position at Independent Health?
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Overview
The Fraud Investigator will develop, implement and administer the IH anti-fraud program, including a regular fraud risk assessment; and project manage the program, facilitating cross functional fraud control owners to ensure overall program effectiveness. This associate will also investigate suspected fraudulent or abusive activity by researching standards of care, reviewing medical record documentation, and other types of documentation, in accordance with Independent Health’s Fraud Prevention Plan. They will review output from the computerized fraud system and make the determination to pay or deny claims.
Qualifications
- Associates degree in Criminal Justice or related field required. Bachelor’s degree preferred. An additional two (2) years of experience will be considered in lieu of degree. Certified Fraud Examiner (CFE) preferred.
- Five (5) years of experience in the healthcare field working in fraud, waste and abuse investigations and audits; insurance claims investigation; or professional investigation with law enforcement agencies OR seven (7) years of experience in professional investigation involving economic or insurance-related matters required.
- Experience with medical insurance claims and medical record reviews/audits using standard coding (HCPC, CPT, ICD-9, ICD-10) required. Experience in a managed care setting preferred.
- Familiarity with insurance investigative processes, provider licensure and quality of care issues preferred.
- Able to work independently with wide latitude of freedom to determine the direction of cases and program coordination activities, including follow up with control owners across the enterprise.
- Ability to assume responsibility, maintain data and reports in consideration of and maximization of confidentiality.
- Knowledge of Microsoft Office with experience in Word and Excel required, knowledge of claims audit software preferred.
- Ability to prepare medical record audit reports.
- Strong organizational skills, verbal and written communication skills.
- Ability to communicate with providers, and efficiently and accurately gather information from provider offices.
- Proven examples of displaying the IH values: Passionate, Caring, Respectful, Trustworthy, Collaborative, and Accountable.
Essential Accountabilities
Assist in identifying potential fraud and gathering the documentation needed to conduct an investigation in accordance with Independent Health’s Fraud Prevention Plan
- Identify medical record issues that provide evidence for cases.
- Research standards of care pertaining to the medical issues identified in the cases.
- Review medical record documentation provided in each case and identify the appropriate course of action.
- Collect, analyze and interpret the clinical data.
- Summarize the clinical findings and provide direction/disposition of the cases.
- Assist in the identification, detection, and prevention of fraudulent/abusive activity.
- Review output from computerized fraud system and make determination to pay or deny claims.
Organize and manage reports/data
- Control and maintain reports, data and documentation of clinical findings for an investigation in an organized manner.
- Identify areas of opportunity for company policies/procedures as identified during analysis.
Develop comprehensive anti-fraud program, including regular fraud risk assessment, coordinating fraud control activities of multiple fraud control point owners across the enterprise, evaluating the strength and effectiveness of the program and regular reporting of results to management.
Immigration or work visa sponsorship will not be provided for this position
Hiring Compensation Range: $62,500 - $77,500 annually
Hiring Compensation Range: $62,500 - $77,500 annually
Compensation may vary based on factors including but not limited to skills, education, location and experience.
In addition to base compensation, associates may be eligible for a scorecard incentive, full range of benefits and generous paid time off. The base salary range is subject to change and may be modified in the future.
As an Equal Opportunity / Affirmative Action Employer, Independent Health and its affiliates will not discriminate in its employment practices due to an applicant’s race, color, creed, religion, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender identity or expression, transgender status, age, national origin, marital status, citizenship and immigration status, physical and mental disability, criminal record, genetic information, predisposition or carrier status, status with respect to receiving public assistance, domestic violence victim status, a disabled, special, recently separated, active duty wartime, campaign badge, Armed Forces service medal veteran, or any other characteristics protected under applicable law.
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Current Associates must apply internally via the Job Hub app.
Salary : $62,500 - $77,500
