Special Investigation Unit Analyst
Special Investigation Unit Analyst
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Not Disclosed
Salary Not Disclosed
1 Vacancy
Job Description
Job Summary
Performs activities related to the detection and investigation of fraud and abuse within Priority Health. Utilizes knowledge/expertise of health care fraud to investigate all types of health care fraud including member employer group agent pharmacy provider etc. Investigates collects and documents findings for management review. Investigation may include research interviews data analysis and substantive desk or onsite medical record review. Responsible for preparing case file final report and ensuring corrective action is taken if applicable. Assists with internal and external education on fraud waste abuse billing and documentations requirements.
Essential Functions
Responsible for investigating collecting researching data to detect fraudulent or abusive practices by utilizing system tools interviews medical records audits data mining perform compliance audits of medical claims fee screens and other payment mechanism to ensure accurate payment.
Investigate fraud and abuse tips received through the compliance hotline internal referral or identify through data analytics. Support information requests my government agencies law enforcement external auditors etc. Conduct telephone and in person interviews which may include members providers employer group agents etc. to determine validity of allegations of fraud waste and abuse. May include conversations with law enforcement and regulatory agencies.
Prepare financial analyses and reports to document finding and maintain up to date case files. Case files to include documentation to substantiate investigative process findings final report. In addition notifications of finding letter for dissemination to provider or affected entity notification letters to regulatory agencies if applicable. Presents provider offers for settlement to management and legal for approval.
Responsible for understanding plan documents provider and agent agreements products offered State and Federal laws related to fraud waste or abuse Medicare and Medicaid regulations etc.
Ability to work effectively with minimal supervision and direction and exhibit good problem-solving skills.
Assists in training of fraud awareness for members providers employer groups agents and vendors.
Qualifications
Required
Bachelors Degree or equivalent Health Business or statistics
2 years of relevant experience Detection prevention and recovery related to abusive and fraudulent practices related to hospital physician pharmacist pharmacy employer group agent or other fraudulent entity.
2 years of relevant experience Related health care experience
One of the following certifications is required:
CRT-Registered Health Information Technician (RHIT) - AAPC American Academy of Professional Coders Upon Hire
CRT-Registered Health Information Administrator (RHIA) - AHIMA American Health Information Management Association Upon Hire
CRT-Professional Coder - AAPC American Academy of Professional Coders Upon Hire
CRT-Professional Coder Certified - Payer (CPC-P) - UNKNOWN Unknown Upon Hire
CRT-Outpatient Coder Certified (COC) - UNKNOWN Unknown Upon Hire
CRT-Coding Specialist (CCS) - AHIMA American Health Information Management Association Upon Hire
CRT-Coding Specialist Certified-Physician Based (CCS-P) - AHIMA American Health Information Management Association Upon Hire
About Corewell Health
As a team member at Corewell Health you will play an essential role in delivering personalized health care to our patients members and our communities. We are committed to cultivating and investing in YOU. Our top-notch teams are comprised of collaborators leaders and innovators that continue to build on one shared mission statement - to improve health instill humanity and inspire hope. Join a nationally recognized health system with an ambitious vision of continued advancement and excellence.
How Corewell Health cares for you
Comprehensive benefits package to meet your financial health and work/life balance goals. Learn more here.
On-demand pay program powered by Payactiv
Discounts directory with deals on the things that matter to you like restaurants phone plans spas and more!
Optional identity theft protection home and auto insurance pet insurance
Traditional and Roth retirement options with service contribution and match savings
Eligibility for benefits is determined by employment type and status
Primary Location
SITE - Priority Health - 1231 E Beltline - Grand RapidsDepartment Name
PH - Special Investigations UnitEmployment Type
Full timeShift
Day (United States of America)Weekly Scheduled Hours
40Hours of Work
8:00 a.m. to 5:00 p.m.Days Worked
Monday to FridayWeekend Frequency
N/ACURRENT COREWELL HEALTH TEAM MEMBERS Please apply through Find Jobs from your Workday team member account. This career site is for Non-Corewell Health team members only.
Corewell Health is committed to providing a safe environment for our team members patients visitors and community. We require a drug-free workplace and require team members to comply with the MMR Varicella Tdap and Influenza vaccine requirement if in an on-site or hybrid workplace category. We are committed to supporting prospective team members who require reasonable accommodations to participate in the job application process to perform the essential functions of a job or to enjoy equal benefits and privileges of employment due to a disability pregnancy or sincerely held religious belief.
Corewell Health grants equal employment opportunity to all qualified persons without regard to race color national origin sex disability age religion genetic information marital status height weight gender pregnancy sexual orientation gender identity or expression veteran status or any other legally protected category.
An interconnected collaborative culture where all are encouraged to bring their whole selves to work is vital to the health of our organization. As a health system we advocate for equity as we care for our patients our communities and each other. From workshops that develop cultural intelligence to our inclusion resource groups for people to find community and empowerment at work we are dedicated to ongoing resources that advance our values of diversity equity and inclusion in all that we do. We invite those that share in our commitment to join our team.
You may request assistance in completing the application process by calling 616.486.7447.
Required Experience:
IC
Employment Type
Full-Time
