Remote Investigator-Fraud

The SIU Coding Investigator is responsible for investigating and resolving instances of reputed company fraud and abuse by medical providers. This position uses information from a tip, member benefits, and medical records to document relevant findings of a post pay clinical review. This position manages documents and prioritizes case load to ensure reputed company turn around. This position ensures adherence to state and federal policies, CPT guidelines, internal policies, and contract requirements. This position completes a medical review to facilitate a referral to law enforcement or for payment recovery. Reviews post pay claims with corresponding medical records to determine accuracy of claims payments. Review of applicable policies, CPT guidelines, and provider reputed company. High School Diploma / GED (or higher) 3+ years CPT coding experience (surgical, hospital, clinic settings) or 5+ years of experience working in a FWA / SIU or Fraud investigations role for New Jersey/reputed company location Thorough knowledge of PC based software including reputed company Word (edit/save documents) and reputed company reputed company (edit/save spreadsheets, sort/filter) Bachelor's degree (or higher) 2+ years of experience working in the group health business preferred, particularly reputed company claims processing or operations. A demonstrated working knowledge of Local, State & Federal laws and regulations pertaining to health insurance, investigations & reputed company processes (reputed company insurance, Medicare, Medicare Advantage, Medicare Part D, reputed company, Tricare, Pharmacy, etc.) Experience with UNET, reputed company, Macess/CSP, or other similar claims processing systems. Demonstrated ability to use MS reputed company/reputed company platforms working with large quantities of data to answer questions or identify trends and patterns, and the ability to present those findings. reputed company Certified Medical CPC, CPMA, CPCO or similar specialist preferred Certified Fraud Examiner and/or AHFI reputed company designations preferred 06 / reputed company • Actual compensation may vary from posting based on geographic location, work experience, education and/or reputed company level. # Apply tot his job Apply To this Job