An ongoing evaluation and auditing process is critical to the successful compliance program. The Office of the Inspector General indicates the necessity of thorough monitoring and the implementation of reporting the findings. The reports of these monitoring should include identified areas of suspected non-compliance, risk assessment and include corrective action. The Fraud Audit Department is responsible for the company's audit functions for determining financial payment accuracy of medical claims as well as system set-up for contract, capitation and fee for service configuration and pre-payment software edits.
The investigator will be in a position of trust, a role that requires integrity, confidentiality, intensity and the utmost commitment in ensuring customer satisfaction through timeliness in meeting or exceeding customer and internal standards.
• Perform in depth analysis and investigation of potential fraudulent healthcare claims and prepare supporting documentation for further actions.
• Utilize data analysis techniques to determine inconsistencies and create leads for auditing purposes.
• Timely and professional documentation of all actions.
• Perform investigative practices (conduct interviews, compile documentation and evidence, maintain extensive notes, negotiate and settle cases, arbitration/litigation testimony).
• Audit cases holistically and see them through to conclusion.
• Work in conjunction with various law enforcement agencies and regulatory bodies.
• Follow all laws, rules and regulations when auditing case files.
• Perform research and draw conclusions
• Interpret laws and regulations as they pertain to each case file.
• Education of providers, facilities, law enforcement and other groups related to each case.
• Accurate, professional and thoroughly organized case files.
• Formatting overpayments based off of review results and proceeding with direct collection from the provider.
ATTRIBUTES / QUALIFICATIONS
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.
• Excellent written and verbal communication and interpersonal skills.
• Ability to exercise independent judgment.
• Ability to work independently and as a member of a team.
• Able to multi-task and prioritize work.
• Ability to “think outside the box” and use information from a variety of sources to make evidence based business decisions guided by policies, procedures and business plans.
• Abides by and demonstrates the company Mission – Vision – Values through both behavior and job performance on a day-to-day basis.
• Convey a strong professional image, exhibit interest and positive attitude toward all assigned work.
• Adheres to and participates in Company’s mandatory HIPAA privacy program / practices and Business Ethics and Compliance programs / practices.
• Reviews and adheres to all company policies, procedures, and the Employee Handbook.
• Must be able to remain in a stationary position 90% of the time.
• Occasionally move about the office to access file cabinets, office machinery, etc.
• Constantly operates a computer and other office productivity machinery (i.e., a calculator, copy machine, and computer printer).
• Frequently communicates via phone and email. Must be able to exchange accurate information in these situations.
• Occasionally lift items weighing up to 10 pounds.
Bachelor’s Degree in Criminal Justice or related field/or 5 years of insurance claims investigation experience. Knowledge of medical coding, ICD10, HCPCS, HIPAA, etc. a plus. Experience and Ability to present issues of concern, citing regulatory violations, alleging schemes or scams to defraud. Proficiency in Microsoft Word, Excel and Access. Strong analytical and technical skills. Must have the ability to handle sensitive and confidential materials.
CareCentrix maintains a drug-free workplace in accordance with Florida’s Drug Free Workplace Law.