Investigative Intake Coordinator

3 weeks ago

Wheeling, United States The Health Plan Full time

The SIU Investigative Intake Coordinator (IIC) is part of a team focused on the prevention, detection, investigation, and reporting of healthcare fraud, waste, and abuse (FWA), program integrity initiatives, and the recovery of overpayments in a multi-payer environment. The IIC provides critical support services to the unit, by coordinating various functions prior to and during the investigative process which facilitates efficiency of, and ultimately better outcomes for, the investigations. The IIC acts as the SIU's Law Enforcement Liaison, utilizing outstanding organizational skills in fulfilling all data requests and analytics for the WV MFCU, the WVOIC, the ODI, the USAO and other law enforcement or regulatory entities. The IIC is also responsible for screening and triaging incoming complaints and preparing cases for investigator review; statistical tracking, and preparation of internal reporting for other THP departments.

Required:

* Associate's degree in any field -OR- at least two (2) years of relevant experience such as: SIU, healthcare fraud investigation, medical claim investigation, healthcare program integrity, data mining or analytics, healthcare claims payment processing, clinical experience, compliance, or certification as AHFI, CPC/CCP/CCS/CMC, or CFE.
* Proficiency in Microsoft Excel; basic proficiency in Word, Outlook and other common programs.
* Strong organizational and analytical skills.
* Detail oriented, with a high level of accuracy.
* Effective written and oral communication skills.
* Ability to plan and execute projects independently and meet tight deadlines.
* Ability to prioritize tasks in an environment with multiple (sometimes competing) priorities.
* Holds a Certified Medical Coder certification (or other commensurate designation; or ability to obtain within 6 months of employment).

Desired:

* Bachelor's degree in Accounting, Business, Criminal Justice, Data Analytics, Health Informatics, Health Information Management, or related field.
* At least three (3) years of relevant experience such as: SIU, healthcare fraud investigation, medical claim investigation, healthcare program integrity, data mining or analytics, healthcare claims payment processing, clinical experience, compliance, or certification as AHFI, CPC/CCP/CCS/CMC, or CFE.
* Proficiency in fraud analytics.
* Experience with SQL/Microsoft Report Builder and Report Manager.
* Experience in Medical Terminology and/or Coding.
* Experience in a federally regulated environment such as Medicaid or Medicare Advantage.

Responsibilities:

* Monitoring/attending to various FWA allegation reporting tools such as: THP fraud hotline, THP FWA Web Portal, SIU/QI Form Submissions;
* Gathering preliminary information on all incoming allegation referrals and preparing them for SIU review, to ensure timely and proper assignment or disposition;
* Entering cases into the case management and tracking system and Analyzing healthcare claims data and other relevant information reactively, in response to allegations of FWA, to ascertain potential exposure;
* Analyzing and synthesizing information from multiple sources including claims data, contracts, enrollment data, provider manuals, educational materials, bulletins, and state and federal regulations, to determine impact on claims payment as it relates to SIU cases or leads;
* Coordinating Responses to requests for information from various sources (primarily WV MFCU), gathering information from multiple departments, validating the information prior to submission, and submitting THP's response;
* Developing an expertise in the use of fraud detection software and case tracking system
* Identifying and recommending process improvements to reduce FWA;
* Tracking, trending, and reporting identified metrics, including all dashboard reporting and assigned OMT Indicators;
* Coordinating deconfliction requests with BMS and MFCU;
* Maintaining technical knowledge and skills by attending professional conferences and trainings, obtaining or retaining professional certification(s), and pursuing constant learning through membership in relevant professional organizations.

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