Overview

Responsible for contributing to in-depth investigations for suspected fraud or abuse with respect to provider, pharmacy, employer, member, and broker interactions involving the full range of products at Optima Health. Responsible for contributing to the review of the quality of pharmacy, physician, ancillary and hospital based coding in routine desk audits as well as occasional on-site audits. Contribute to the review of reimbursement systems relating to health insurance claims processing and ensures adherence to Optima Health policies and procedures for its various product offerings. Specific progression of responsibility is a follows dependent upon education, certifications, and experience: Identify, investigate, analyze and evaluate instances of potential fraud, waste, and abuse. Conduct interviews or correspond with patients, providers, witnesses or other relevant parties to determine settlement, denial, or review. Analyze information gathered by investigation and report findings and recommendations as a written summary and/or presentation. Learn and conduct statistical sampling of complex medical claims. Assists in drafting settlements.<br /><br />Qualifications<br /><br /><strong>Education Level</strong><br />Bachelor's Level Degree<br /><br /><strong>Experience</strong><br />Required: Coding – 2 years, Healthcare – 2 years, Internal/External Audit – 2 years, Regulatory/Compliance – 2 years, Related – 3 years<br /><br />Preferred: None, unless noted in the "Other" section below<br /><br /><strong>License</strong><br />None, unless noted in the "Other" section below<br /><br /><strong>Skills</strong><br />Required: Complex Problem Solving, Critical Thinking, Microsoft Excel, Speaking, Time Management, Writing<br /><br />Preferred: Microsoft Access<br /><br /><strong>Other</strong><br />Bachelor's Degree in related field required Minimum of 2 years combined experience required in Medical Coding OR Healthcare (Medical Chart Review/Insurance Billing) OR Internal/External Audit OR Regulatory/Compliance OR Claims Investigations OR Criminal Investigation/White Collar Crime Certified Professional Coder required (or achieved within 12 months of hire date) Certified Fraud Examiner (CFE) or Accredited Health Care Fraud Investigator (AHFI) preferred. Job Skills: Certified Fraud Examiner (CFE) Accredited Health Care Fraud Investigator (AHFI) Professional Writing, Verbal Communication, Time Management Complex Problem Solving/Critical Thinking Microsoft Excel and Word Microsoft Access and Outlook preferred


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