CareCentrix

  • Fraud Investigator II

    Job Locations US-CT-Hartford | US-FL-Tampa
    Job ID
    2018-5254
  • Overview

    Come join a dynamic, growing team in an innovative, game-changing, healthcare organization. CareCentrix is committed to making the home the center of patient care.

     

    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.

     

    Responsibilities

     

    • 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.
    • Reporting

     

    Qualifications

    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.

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