SIU Investigator (Clinical Nurse Investigator)
Location: Bat! on Rouge Louisiana
Description: Magellan Health Services is presently looking of SIU Investigator (Clinical Nurse Investigator) right now, this position will be placed in Louisiana. More complete informations about this position opportunity kindly see the descriptions. Job Summary
This position is responsible for comprehensive management and ownership of fraud, waste and abuse investigations including development and presentation of investigative results. This individual carries out analytical and process management tasks with a high degree of autonomy. This individual serves as a corporate resource on fraud, waste and abuse issues and recommends cost containment projects with an emphasis on fraud prevention.
Essential Functions
FRAUD, WASTE AND ABUSE DETECTION
Triage and pr! ioritize leads from internal and external sources
Use knowledge of healthcare coding conventions, fraud schemes, and general areas of vulnerability, reimbursement methodologies, and relevant laws to find suspicious patterns in claims data, provider enrollment data, and other sources
Remain up to date on published fraud cases, schemes, investigative techniques and methodologies, and industry trends INVESTIGATIONS
Prioritize, triage and manage workload to meet internal performance metrics, regulatory and contractual requirements
Use independent judgment to create investigative work plans and develop case strategies based upon analysis of referral data and contractual/regulatory requirements
Analyze data and select audit samples using various sampling methodologies
Plan and conduct desk audits, field audits and/or site visits
Collect and analyze information to evaluate facts and circumstances through an extensive review of data from professiona! l and facility providers, member data, contractual relationships, payment policies, Medicaid/Medicare rules and statutes, etc.
Conduct research on medical policies and practices, provider characteristics, and related topics
Interview patients, providers, provider staff, and other witnesses/experts
Prepare correspondence
Obtain and preserve physical and documentary evidence to support investigations
Maintain comprehensive case files PACKAGING OF FINDINGS AND RECOMMENDATIONS
Organize data and prepare a written summary of investigative steps, conclusions, recommendations with attention to detail and a high level of accuracy
Prepare clear and concise investigatory reports to support findings of potential fraud, waste and abuse CASE RESOLUTION
Identify, communicate and recover losses as deemed appropriate
Present case to internal department(s), law enforcement and/or regulatory agencies
Support legal proceedings as needed, includ! ing testifying in court or working with law enforcement personnel to pr! epare cases for civil or criminal actions
Negotiate settlement agreements with subjects and/or attorneys
Assist in preparation, execution, and follow-up of settlement agreement terms CUSTOMER INTERACTIONS
Make presentations to customers, prospects, conference audiences, and law enforcement
Collaborate, consult, and coordinate regularly with clients on the status and direction of assignments
Develop and maintain contacts/liaisons with law enforcement, regulatory agencies, task force members, other company SIU staff and external contacts involved in fraud investigation, detection and prevention MISCELLANEOUS DUTIES
Represent client at industry task force meetings and meetings with regulatory agencies
Measure and report performance metrics
Identify opportunities and make recommendations for reduction of exposure to fraud, waste and abuse
Consult on anti-fraud policies and procedures
Other duties as deemed appropriate
M! inimum Requirements
Education : BA/BS
Experience: 5-8 Years
Industry : Minimum of five years fraud investigations, claims processing, auditing or provider networks at expert level
Knowledge, Skills, Abilities: Demonstrated abilities in time management and establishing priorities
Strong listening and observation skills.
Impeccable work ethic, completely dependable, and proactive; a problem solver
Proven ability to effectively handle cases of fraud and abuse in a discreet, confidential, and professional manner
Intermediate to high computer skills consisting of Microsoft Excel, Access, Outlook,Demonstrated strategic and analytical thinking skills, with ability to effectively communicate conclusions and recommendations to management
Comprehensive, practical knowledge of complex and diverse fraud investigative techniques and methodologies utilized in program audits
! Ability to work to tight timelines when necessary
Works independently; collaborates well with peers and customers
Willingness to travel approximately 20% of the time
Demonstrated ability to manage and prioritize case load with limited supervision
Technical Skills Word, and Power Point.
Licenses, Certifications, etc.: Certifications a plus: Certified Professional Coder (CPC), Accredited Healthcare Fraud Investigator (AHFI), and Certified Fraud Examiner (CFE), Certified Healthcare Chart Auditor (CHCA), etc.
Preferred Qualifications
Experience : Understanding of and experience with Medicaid/Medicare requirements preferred Bilingual, IT, accounting and medical background desirable. Prior prosecution experience or experience working with FBI, HHS-OIG Assistant U.S. Attorneys, or State Attorney Generals helpful
Knowledge, Skills, Abilities : Knowledge of managed health care business model! and processes, preferably in behavioral health, radiology or pharmacy
- .
If you were eligible to this position, please email us your resume, with salary requirements and a resume to Magellan Health Services.
If you interested on this position just click on the Apply button, you will be redirected to the official website
This position starts available on: Mon, 09 Dec 2013 21:01:15 GMT