Claims Examiner / Special Investigative Unit - SIU
Special Investigative Unit - SIU Location:
Columbia, MD 21046 Pay Rate:
$20 per hour 40 hours per week/ Monday-Friday Job Details:
FRAUD, WASTE AND ABUSE DETECTION :
Maintains caseload of incidents with low to medium priority and complexity.
Prioritize and manage workload to meet internal performance metrics, regulatory and contractual requirements.
Analyze data to find suspicious patterns and outliers using knowledge of healthcare coding conventions, fraud schemes, and general areas of vulnerability.
Contact referrer, member, provider, or witnesses to gather additional information, facts and supporting documentation.
Collaborate and refer non-SIU related issue and activities to external departments (Cost Containment, Networks, Clinical) for handling.
PACKAGING OF FINDINGS AND RECOMMENDATIONS:
Organize data and document preliminary investigative steps with a high level of detail and accuracy, to clearly and concisely support conclusions and recommendations Demonstrated strategic and analytical abilities to review and evaluate information such as claims data, suspicious patterns and other supporting information related to case allegation.
Requires the verbal, written and interpersonal skills to effectively interact and communicate conclusions and recommendations to management and customers.
.
CFE - Certified Fraud Examiner credential preferred.
Bachelor's degree preferred.
Prefer knowledge of managed health care business model and processes, preferably in behavioral health, radiology or pharmacy.
Skills and
Qualifications:
Has a solid command of the claims/SIU policies and procedures; exhibits sound interpretation of policies & procedures in resolving claims.
3
years' fraud investigations/claims experience Ability to manage workload while simultaneously working on multiple projects and cases with timely and accurate results with limited supervision.
Knowledge of ICD-9/10, CPT/HCPS/Revenue codes, insurance terms and policy interpretation.
Demonstrated strategic and analytical abilities to review and evaluate information such as claims data, suspicious patterns and other supporting information related to case allegation.
Requires the verbal, written and interpersonal skills to effectively interact and communicate conclusions and recommendations to management and customers.
Proficient with Microsoft Office Word, Excel and PowerPoint with ability to quickly learn and use new software applications.
Knowledge of ICD-9/10, CPT/HCPS/Revenue codes, insurance terms and policy interpretation.
CFE - Certified Fraud Examiner credential preferred.
Bachelor's degree preferred.
Prefer knowledge of managed health care business model and processes, preferably in behavioral health, radiology or pharmacy.
WORK
Experience:
Claims, Fraud Investigations 3
years CERTIFICATIONS:
CFE - Certified Fraud Examiner EDUCATION:
Bachelors (Preferred) Please apply to if interested Allison Ginotti Keywords:
Investigations, Investigator, Detective, Claims Examiner, Managed Care, Fraud Schemes, Fraud Abuse, CFE, Fraud Alert, SIU, Healthcare Coding Conventions, Revenue Codes, Fraud Alerts, Fraud Abuse, Fraud, Special Investigative Unit, Investigation, Claims Examiner, Fraud Schemes,.
Estimated Salary: $20 to $28 per hour based on qualifications.
Columbia, MD 21046 Pay Rate:
$20 per hour 40 hours per week/ Monday-Friday Job Details:
FRAUD, WASTE AND ABUSE DETECTION :
Maintains caseload of incidents with low to medium priority and complexity.
Prioritize and manage workload to meet internal performance metrics, regulatory and contractual requirements.
Analyze data to find suspicious patterns and outliers using knowledge of healthcare coding conventions, fraud schemes, and general areas of vulnerability.
Contact referrer, member, provider, or witnesses to gather additional information, facts and supporting documentation.
Collaborate and refer non-SIU related issue and activities to external departments (Cost Containment, Networks, Clinical) for handling.
PACKAGING OF FINDINGS AND RECOMMENDATIONS:
Organize data and document preliminary investigative steps with a high level of detail and accuracy, to clearly and concisely support conclusions and recommendations Demonstrated strategic and analytical abilities to review and evaluate information such as claims data, suspicious patterns and other supporting information related to case allegation.
Requires the verbal, written and interpersonal skills to effectively interact and communicate conclusions and recommendations to management and customers.
.
CFE - Certified Fraud Examiner credential preferred.
Bachelor's degree preferred.
Prefer knowledge of managed health care business model and processes, preferably in behavioral health, radiology or pharmacy.
Skills and
Qualifications:
Has a solid command of the claims/SIU policies and procedures; exhibits sound interpretation of policies & procedures in resolving claims.
3
years' fraud investigations/claims experience Ability to manage workload while simultaneously working on multiple projects and cases with timely and accurate results with limited supervision.
Knowledge of ICD-9/10, CPT/HCPS/Revenue codes, insurance terms and policy interpretation.
Demonstrated strategic and analytical abilities to review and evaluate information such as claims data, suspicious patterns and other supporting information related to case allegation.
Requires the verbal, written and interpersonal skills to effectively interact and communicate conclusions and recommendations to management and customers.
Proficient with Microsoft Office Word, Excel and PowerPoint with ability to quickly learn and use new software applications.
Knowledge of ICD-9/10, CPT/HCPS/Revenue codes, insurance terms and policy interpretation.
CFE - Certified Fraud Examiner credential preferred.
Bachelor's degree preferred.
Prefer knowledge of managed health care business model and processes, preferably in behavioral health, radiology or pharmacy.
WORK
Experience:
Claims, Fraud Investigations 3
years CERTIFICATIONS:
CFE - Certified Fraud Examiner EDUCATION:
Bachelors (Preferred) Please apply to if interested Allison Ginotti Keywords:
Investigations, Investigator, Detective, Claims Examiner, Managed Care, Fraud Schemes, Fraud Abuse, CFE, Fraud Alert, SIU, Healthcare Coding Conventions, Revenue Codes, Fraud Alerts, Fraud Abuse, Fraud, Special Investigative Unit, Investigation, Claims Examiner, Fraud Schemes,.
Estimated Salary: $20 to $28 per hour based on qualifications.
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