Senior Investigator
1199SEIU Benefit and Pension Funds · New York City, New York, US
Responsibilities • Conducts investigations into allegations of fraud, waste, or abuse, including preliminary assessments and full end-to-end case work. • Rev...
Job description
Responsibilities: - Conducts investigations into allegations of fraud, waste, or abuse, including preliminary assessments and full end-to-end case work. - Reviews and analyzes medical records, claims data, enrollment data, and other documentation to evaluate potential FWA. - Performs coding, billing, reimbursement, and medical necessity assessments based on CPT, HCPCS, ICD-9/10, DRG, and related coding guidelines. - Uses advanced data mining techniques to identify aberrant billing patterns, outliers, and other indicators of fraudulent activity. - Produces reliable, accurate and timely written investigative reports for internal and/external review detailing investigation findings, based on industry standard(s) and/or internal policy and procedure. - Recommends possible interventions for loss control and risk avoidance based on the outcome of the investigation. - Coordinates with various internal customers to gather documentation pertinent to investigations. - Incorporates communication skills to work with physicians, other health professionals, attorneys as well as external regulatory agencies and law enforcement personnel. - Communicate effectively and collaboratively with internal...