About this role
Role Overview
- Serves as an entry level professional who develops baseline plans for ensuring the integrity and accuracy of claims processes and protocols.
- Collects data for audits/investigations into claims, utilizing a combination of analytical skills and attention to detail, reviewing documentation, interviewing involved parties, and communicating with various stakeholders to gather relevant information for successful resolution and closure.
- Identifies opportunities to target fraud, waste, and abuse or discrepancies in claims submissions.
- Adheres to industry regulations and company policies for managerial follow-up.
- Analyzes data in order to effectively assess the validity of claims.
- Provides accurate recommendations to management for claim resolution and closure.
- Documents and inputs all findings, while preparing comprehensive reports that may be used for legal or audit/investigative purposes.
Requirements
- Minimum Bachelor's Degree required
- 0
- 2 years of experience required; 2
- 4 years preferred
- Medicaid experience preferred
- Certified Fraud Examiner or Accredited Healthcare Anti-Fraud Investigator preferred