Job Description:
Investigator I
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.
More jobs in St. Louis, Missouri
|
Compass Health Network |
|
American Water |
|
BWAY |