Investigator 1 – FWA Prepayment Review

Who We Are

Point32Health is a leading not-for-profit health and well-being organization dedicated to delivering high-quality affordable healthcare. Serving nearly 2 million members Point32Health builds on the legacy of Harvard Pilgrim Health Care and Tufts Health Plan to provide access to care and empower healthier lives for everyone. Our culture revolves around being a community of care and having shared values that guide our behaviors and decisions. Weve had a long-standing commitment to inclusion and equal healthcare access and outcomes regardless of background; its at the core of who we are. We value the rich mix of backgrounds perspectives and experiences of all of our colleagues which helps us to provide service with empathy and better understand and meet the needs of the communities where we serve live and work.

We enjoy the important work we do every day in service to our members partners colleagues and communities. Learn more about who we are at Point32Health.

Job Summary

Job Description

Key Responsibilities/Duties what you will be doing (top five):

• Conducting prepayment investigations involving internal and external research detailed data analysis review of medical records and interviews of members providers and other third parties.
• Navigating prepayment processes involving existing and upcoming FWA schemes.
• Handling substantial prepayment claims including extensive administrative tasks review of medical records and communicating with providers through the prepayment Hotline.
• Applying laws regulations plan policies and guidelines contract provisions coding rules coverage rules and industry standards to information gathered during the investigation.
• Preparing reports of investigative findings and reporting investigative findings to providers.
• Working with SIU management to educate providers recover overpayments take action to prevent future loss and monitor provider activity post-investigation
• Identifying root causes of fraud waste and abuse and recommending internal and external corrective actions to address these root causes.
• Recommending investigative priorities strategies and techniques.
• Working with the analytics and intake team to develop and refine data mining to address new and evolving schemes.
• Sharing expertise and promoting investigative best practices among SIU management and staff. Educating and collaborating with various business units to raise awareness of potential FWA concerns.
• Performing out-of-the-box thinking collaborate with others and make a difference every day!
• Other duties as assigned by the Manager Pre-Payment Review

Qualifications what you need to perform the job

Certification and Licensure

• Certified Professional Coder (CPC); Certified Fraud Examiner (CFE) designation a plus.

Education

• Required (minimum): Bachelors degree
• Preferred: Degree in a clinical or scientific field business accounting computer science or criminal justice

Experience

• Required (minimum): 1-3 years related experience in health insurance fraud investigations.
• Preferred: Related experience in audits/investigations.

Skill Requirements

• Ability to produce clear concise and well-organized documents.
• Resilient collaborative flexible innovative.

Working Conditions and Additional Requirements (include special requirements e.g. lifting travel):

• Must be able to work under normal office conditions and work from home as required.
• May be required to attend meetings at other company locations or other external meetings.
• May be required to perform on-site evaluations of provider practice locations
• Work may require simultaneous use of a telephone/headset and PC/keyboard and sitting for extended durations.
• May be required to work additional hours beyond standard work schedule.

Disclaimer

The above statements are intended to describe the general nature and level of work being performed by employees assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities duties and skills required of employees assigned to this position. Management retains the discretion to add to or change the duties of the position at any time.

Salary Range

Compensation & Total Rewards Overview

The annual base salary range provided for this position represents a range of salaries for this role and similar roles across the organization. The actual salary for this position will be determined by several factors including the scope and complexity of the role; the skills education training credentials and experience of the candidate; as well as internal equity. As part of our comprehensive total rewards program colleagues are also eligible for variable pay. Eligibility for any bonus commission benefits or any other form of compensation andbenefits remains in the Companys sole discretion and maybe modified at the Companys sole discretion consistent with the law.

Point32Health offers their Colleagues a competitive and comprehensive total rewards package which currently includes:

• Medical dental and vision coverage

• Retirement plans

• Paid time off

• Employer-paid life and disability insurance with additional buy-up coverage options

• Tuition program

• Well-being benefits

• Full suite of benefits to support career development individual & family health and financial health

For more details on our total rewards programs visit welcome all
All applicants are welcome and will receive consideration for employment without regard to race color religion gender gender identity or expression sexual orientation national origin genetics disability age or veteran status.

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