Remote Investigator-Fraud

The SIU Coding Investigator is responsible for investigating and resolving instances of healthcare fraud and abuse by medical providers. This position uses information from a tip, member benefits, and medical records to document relevant findings of a post pay clinical review. This position manages documents and prioritizes case load to ensure timely turn around. This position ensures adherence to state and federal policies, CPT guidelines, internal policies, and contract requirements. This position completes a medical review to facilitate a referral to law enforcement or for payment recovery. Reviews post pay claims with corresponding medical records to determine accuracy of claims payments. Review of applicable policies, CPT guidelines, and provider contracts. High School Diploma / GED (or higher) 3+ years CPT coding experience (surgical, hospital, clinic settings) or 5+ years of experience working in a FWA / SIU or Fraud investigations role for New Jersey/New York location Thorough knowledge of PC based software including Microsoft Word (edit/save documents) and Microsoft Excel (edit/save spreadsheets, sort/filter) Bachelor's degree (or higher) 2+ years of experience working in the group health business preferred, particularly within claims processing or operations. A demonstrated working knowledge of Local, State & Federal laws and regulations pertaining to health insurance, investigations & legal processes (Commercial insurance, Medicare, Medicare Advantage, Medicare Part D, Medicaid, Tricare, Pharmacy, etc.) Experience with UNET, Comet, Macess/CSP, or other similar claims processing systems. Demonstrated ability to use MS Excel/Access platforms working with large quantities of data to answer questions or identify trends and patterns, and the ability to present those findings. AAPC Certified Medical CPC, CPMA, CPCO or similar specialist preferred Certified Fraud Examiner and/or AHFI professional designations preferred 06 / HOURLY • Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. #