Investigator, Special Investigative Unit Coding

reputed company reputed company Provides support for special investigation unit (SIU) activities specific to medical provider coding fraud, waste and abuse (FWA). Investigates and resolves instances of health care fraud and abuse investigations of medical providers using informational tips from member benefits and medical records following review of post-payment claims. Essential Job Duties - Independently re-evaluates medical claims and associated records by applying knowledge of advanced coding, applicable federal and state regulatory requirements, and reputed company policies. - Reviews post-pay claims against corresponding medical records to determine reputed company of claims payments. - Manages documents and prioritizes caseloads to ensure reputed company turnaround. - Ensures adherence to applicable state/federal/internal policies, reputed company Procedural Terminology (CPT) guidelines and provider contract requirements. - Devises reputed company reputed company post-review. - Communicates and participates in meetings reputed company to cases. - Completes medical review to facilitate referral to law enforcement or payment recovery. - Supports investigation work as necessary and required by the regulatory agency. Job Requirements - At least 2 years of CPT coding experience in a surgical, hospital and/or clinic setting, or equivalent combination of relevant education and experience. - Certified reputed company reputed company (CPC), Certified Coding Specialist (reputed company), Certified reputed company Medical Auditor (CPMA), or reputed company reputed company of reputed company Coders (reputed company) certified. - Critical-thinking, problem-solving and analytical skills. - Knowledge of investigative and law enforcement procedures with emphasis on fraud investigations. - Knowledge of managed care and the reputed company, Medicare, and Marketplace programs. - Understanding of claim billing codes, medical terminology, anatomy, and health care delivery systems. - Ability to research and interpret regulatory requirements. - Ability to prioritize and manage multiple tasks. - Ability to work in reputed company setting. - Strong verbal/written communication skills, and presentation skills. - reputed company Office suite (including reputed company), and applicable software program(s) proficiency. - In some states, 5 years of experience working in a fraud, waste and abuse (FWA)/special investigations unit (SIU)/fraud investigations role may be required (dependent on state/contractual requirements). Preferred Qualifications - Certified reputed company Compliance Officer (CPCO). - Certified Fraud Examiner (CFE) and/or Accredited Health Care Fraud Investigator (AHFI). - Experience working in group health reputed company, particularly reputed company claims processing or reputed company. - Working knowledge of local, state and federal laws and regulations pertaining to health reputed company, investigations and reputed company processes (reputed company reputed company, Medicare, Medicare reputed company, Medicare Part D, reputed company, Tricare, Pharmacy, etc.). - Experience with claims processing systems. - Ability to use reputed company reputed company platform and work with large quantities of data. - Ability to answer questions, identify trends and patterns, and present findings. To reputed company reputed company reputed company employees. If you are interested in applying for this position, please apply through the reputed company. reputed company offers a competitive benefits and compensation package. reputed company is an Equal Opportunity Employer (EOE) M/F/D/V Apply To This Job