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Special Investigative Analyst
4 months ago
Grounded by a compelling mission, core values, and compassion for people, CDPHP and its family of companies offer a strong foundation for a rewarding career. Established in 1984, CDPHP is a physician-founded, member-focused, and community-based not-for-profit health plan that offers high-quality affordable health insurance to members throughout New York. The company values people, quality, innovation, and community, and its corporate culture supports those values wholeheartedly. CDPHP is committed to fostering a culture of belonging and takes a wholistic approach to diversity, equity, and inclusion. At CDPHP, the employees have a voice and are encouraged to make an impact at both the company and community levels through engagement and volunteer opportunities. CDPHP invests in employees who share these values and invites you to be a part of that experience.
The Special Investigative Analyst will be responsible for researching, investigating, and resolving instances of healthcare fraud and/or abusive conduct by internal employees, the medical profession, insured members, or the broker community. They will conduct interviews with providers, members, employees, or informants, utilize data mining and conduct medical record review to identify suspicious trends and patterns and enrollment and billing aberrancies. They will work collaboratively with other departments to identify potential or current sources of abuse and waste and formulate an appropriate plan of education and action to resolve and prevent any occurrences. The Analyst will present findings to health care providers and negotiate resolution of issues. They will be responsible to recognize and analyze violations of CDPHP contracts, State and Federal law and standard billing practices and report any illegal activities in accordance with all laws and regulations to the appropriate internal staff and governmental agencies to support a management decision to pursue criminal, civil or other recovery action on the basis of fraud, waste, or abuse.
**QUALIFICATIONS**:
- Registered Nurse or Licensed Practical Nurse with valid New York State registration or license required.
- Associate’s degree or two (2) years of equivalent experience required
- Certified Professional Coder (CPC®) Certification is preferred or required to be obtained within 1 year of employment.
- Certified Outpatient Coder (COC) Certification is preferred.
- Accredited Health Care Fraud Investigator (AHFI®) accreditation to be obtained once the required AHFI criteria is met will be required.
- Minimum of two (2) years of experience in reviewing and accessing medical / hospital claims in the health insurance industry required.
- Minimum two (2) plus years of experience interpreting medical records and/or investigating and contributing to the resolution of complex claims required.
- Experience in CPT, HCPCS, DRG, and ICD-9 coding with strong knowledge of health care benefits and claims processing systems is preferred.
- Knowledgeable of payment methodologies preferred.
- Knowledge of local, state, and Federal laws and regulations pertaining to insurance required.
- General knowledge of claims payment, processing and systems preferred.
- Experience working with law enforcement and/or testifying in Federal and State court proceedings preferred.
- Experience with Microsoft Office, including Word, Excel, Outlook, and PowerPoint is required, experience with Access preferred.
- Demonstrated ability to identify and determine fraudulent activity and compile necessary documentation in a clear concise manner.
- Demonstrated ability to analyze claims to determine correct processing.
- Demonstrated ability to present complex information in a digestible manner to both internal and external parties.
- Demonstrated knowledge of broker responsibilities and requirements.
- Demonstrated analytical, decision making, and problem-solving skills.
- Demonstrated ability to work collaboratively with multiple partners to positively affect outcomes at the team, organization, and member level.
- Must be detail-oriented with strong organizational skills, including the ability to coordinate workflow.
- Demonstrated ability to provide excellent customer service and develop relationships both internally and externally.
- Demonstrated ability to work with and maintain confidential information.
- Excellent verbal and written communication skills.
- Flexibility to adapt to a changing and fast-paced environment.
CDPHP and its family of companies include subsidiaries Strategic Solutions Management Consultants (SSMC), Practice Support Services (PSS), and ConnectRx Services, LLC.
