Clinical Investigator - Payment Integrity

POSITION SUMMARY

The primary purpose of this role is to investigate and detect potential health care fraud, waste and abuse (FWA) through the monitoring and auditing of medical records to identify inappropriate billing practices and determine medical necessity through extensive review of claims data, policies and procedures, state/federal rules and the interpretation of practice standards. Responsible for preventing, detecting, investigating and correcting incidents of health care fraud, waste and abuse (FWA). This may include, but is not limited to: identification of aberrant coding and/or billing patterns through utilization review, investigations of medical professionals, non-medical professionals, beneficiaries, brokers/sales agents, employees, or business partners and contracted entities.

PRIMARY ACCOUNTABILITIES

1. Function as a clinical subject matter expert (SME) regarding all aspects of healthcare FWA, including but not limited to: claims analysis, medical record reviews, detection, prevention and corrective action remedies.
2. Provide clinical support, training, and FWA expertise to new associates, providers/facilities, Health Plan departments, Health First entities and other vendor and/or Health Plan delegated entities.
3. Receive, log, and thoroughly document all incoming FWA complaints, incidents and leads.
4. Maintain and manage daily case review assignments, with a high emphasis on quality and recovery, prevention, and cost avoidance.
5. Develop, maintain and update FWA policies, procedures, best practices and guidelines.
6. Identify aberrant billing patterns and trends, evidence of fraud, waste or abuse, and recommends providers to be flagged for review within complex data reports.
7. Conduct field operations to include surveillance, facility inspections and potential on-site desk audits.
8. Perform multifaceted retrospective and prepayment reviews of claims, which may require interpretation of state and federal coverage guidelines, applicable benefit language, medical and reimbursement policies, coding requirements and consideration of relevant clinical information on claims with aberrant billing patterns.
9. Perform clinical coding reviews to ensure accuracy of medical coding and utilizes clinical expertise and judgment to determine correct coding and billing accuracy.
10. Contact and interview members, providers, and third parties to validate services; arrange and conduct meetings with providers, employees, business partners, regulatory agencies and law enforcement as required.
11. Prepare summary and/or detailed reports on investigative findings for referral to leadership, federal and state agencies to include, but not limited to, the MEDIC, DOI, FBI, HHS-OIG, and local law enforcement.
12. Responsible for collaboration with Provider Disputes, Appeals/Grievances and second level appeal reviews.
13. Develop and maintain contacts/liaison with law enforcement, regulatory agencies, task force members, and professional associations, other internal and external contacts involved in fraud investigation.

MINIMUM QUALIFICATIONS

• Education: Bachelor’s Degree
• Licensure: Unrestricted RN license
• Certification: None
• Work Experience:

1. 5 years of CPT/HCPCS/ICD-9/ICD-10/DRG coding knowledge/experience with strong knowledge of health insurance claims payments, including knowledge of industry terminology, and regulatory guidelines.
2. 5 years clinical experience with broad clinical knowledge.
3. 1 year experience with Health Plan Payment Integrity or Fraud, Waste and Abuse.

• Work Experience in lieu of Education: none
• Knowledge/Skills/Abilities:

1. Strong computer skills including strong knowledge of Word, Access, and Excel.
2. Excellent organizational and time management skills.
3. Excellent interpersonal and communication skills.
4. Ability to analyze complex tasks, systems, and problems.

PREFERRED QUALIFICATIONS

• Education: No additional education required
• Licensure: No additional required
• Certification: No additional required
• Work Experience: No additional required
• Knowledge/Skills/Abilities: No additional required

PHYSICAL REQUIREMENTS

Majority of time involves sitting or standing; occasional walking, bending, stooping.

• Long periods of computer time or at workstation.
• Light work that may include lifting or moving objects up to 20 pounds with or without assistance.
• May be exposed to inside environments with varied temperatures, air quality, lighting and/or low to moderate noise.
• Communicating with others to exchange information.
• Visual acuity and hand-eye coordination to perform tasks.
• Workspace may vary from open to confined.
• May require travel to various facilities within and beyond county perimeter; may require use of personal vehicle.

ABOUT HEALTH FIRST

At Health First, diversity and inclusion are essential for our continued growth and evolution. Working together, we strive to build and nurture a culture that recognizes, encourages, and respects the diverse voices of our associates. We know through experience that different ideas, perspectives, and backgrounds create a stronger and more collaborative work environment that delivers better results. As an organization, it fuels our innovation and connects us closer to our associates, customers, and the communities we serve.