Clinical Fraud Investigator II

Role Overview

• Performs comprehensive analysis and clinical evaluation of the collected data
• Performs in-depth investigations on identified providers as warranted
• Examines claims for compliance with relevant billing and processing guidelines
• Review and conducts retrospective analysis of claims and medical records prior to payment
• Researches new healthcare related questions as necessary to aid in investigations
• Collaborates with the Special Investigation Unit and other internal areas on matters of mutual concern
• Recommends possible interventions for loss control and risk avoidance based on the outcome of the investigation

Requirements

• Requires an Associate Degree in Nursing and/or current certification as a Certified Professional Coder (AAPC or AHIMA)
• minimum of 4 years related experience
• minimum of 1 year experience in a Clinical Fraud and Abuse Investigation area
• Advanced Excel skills, including Pivot Tables

Benefits

• merit increases
• paid holidays
• Paid Time Off
• incentive bonus programs
• medical, dental, vision
• short and long term disability benefits
• 401(k) +match
• stock purchase plan
• life insurance
• wellness programs
• financial education resources