What are the responsibilities and job description for the Senior Investigator position at 1199SEIU Benefit and Pension Funds?
Requisition #:
7462
# of openings:
1
Employment Type
Full time
Position Status
Permanent
Category
Non-Bargaining
Workplace Arrangement
Hybrid
Fund
1199SEIU National Benefit Fund
Job Classification
Exempt
Responsibilities
7462
# of openings:
1
Employment Type
Full time
Position Status
Permanent
Category
Non-Bargaining
Workplace Arrangement
Hybrid
Fund
1199SEIU National Benefit Fund
Job Classification
Exempt
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 staff, leadership and external customers in a professional manner.
- Conducts settlement negotiations with providers and/or attorneys.
- Maintain the confidentiality required of the organization and the department.
- Follow all Health Insurance Portability and Accountability Act (HIPAA) and Personal Health Information (PHI) requirements and regulations
- Bachelor’s degree in business, criminal justice or related field.
- Certified Professional Coder (CPC), Accredited Healthcare Fraud Investigator (AFHI), Certified Insurance Fraud Investigator (CIFI), and/or Certified Economic Crime Forensic Examiner (CECFE) preferred (but not required).
- Minimum three (3) years’ experience with medical coding and medical record review performed required.
- Minimum three (3) years’ experience in healthcare industry within a Special Investigation Unit (SIU) or equivalent governmental agency responsible for investigating healthcare fraud required.
- Knowledge of medical coding and medical terminology.
- Experience using STARSSolutions or other healthcare FWA case management and detection software preferred (but not required).
- Proven track record in conducting investigations and/or the identification and pursuit of the recovery of overpayments.
- Excellent report writing skills.
- Knowledge of claims processing, reimbursement procedures, and a solid understanding of fraud detection and prevention practices.
- Knowledge of data analysis of claims and documenting findings on spreadsheets.
- Proficiency in Microsoft Office/Suite applications (Excel, Word, PowerPoint, Outlook, etc.).
- Excellent interpersonal and communication skills – oral, written and listening.