Location: This position will work a hybrid model (remote and office). The ideal candidate will live within 50 miles of our St. Louis, Missouri or Winston-Salem, NC and Durham, NC PulsePoint location.
The INVESTIGATOR I is responsible for investigating assigned cases, collecting, researching and analyzing claim data in order to detect fraudulent, abusive or wasteful activities/practices
How you will make an impact:
Using appropriate system tools and databases for analysis of data and review of professional and facility claims to detect fraudulent, abusive or wasteful healthcare insurance payments to providers and subscribers.
Preparation of statistical/financial analyses and reports to document findings and maintain up-to-date electronic case files for management review.
Preparation of final case reports and notification of findings letters to providers.
Receive offers of settlement for review and discussion with management.
Communication skills, both oral and written required for contact with all customers, internal and external, regarding findings.
Minimum Requirements:
Requires a BA/BS and minimum of 2 years related experience preferably in healthcare insurance departments such as Grievance and Appeals, Contracting or Claim Operations, law enforcement; or any combination of education and experience, which would provide an equivalent background.
Preferred Skills, Capabilities and Experiences:
Fraud certification from CFE, AHFI, AAPC or coding certificates preferred.
Knowledge of Plan policies and procedures in all facets of benefit programs management with heavy emphasis in negotiation preferred.
Health insurance, law enforcement experience preferred.
