Clinical Special Investigator - RN/CRNP/PA

Position Description:

The Clinical Special Investigator is responsible for identifying and investigating suspected cases of claim and program fraud waste or abuse. The clinical special investigator is responsible for proactive review of claims reports and the anti-fraud software reports for the purpose of identifying and initiating an investigation The clinical investigator will apply clinical standards, medical policies and coding guidelines when reviewing medical records and claims data to identify areas of potential overpayments. Furthermore, the clinical special investigator will work with the medical director to provide a clinical/coding summary and to complete cases based on the findings. Throughout the process the clinical special investigator is expected to maintain detailed documentation including interview notes, investigative steps and summaries and case outcomes. The clinical special investigator will be able to communicate effectively in writing and orally case findings, coding guidelines and be able to explain all aspects of the case as needed internally, externally with providers, law enforcement or other professional organizations. The clinical special investigator will actively participate in the development and annual review of policies, procedures, and desktops.

Responsibilities and Qualifications:

• Identify and investigate cases of suspected fraud waste or abuse to include independent analysis of claim data to identify potential anomalies
• Independently conduct research related to the investigation
• Communicate cross departmentally and externally with providers, members or other entities during the course of the investigation to establish the facts/merits of a case
• Perform medical record reviews and apply policies, and coding guidelines
• Maintain well documented case files
• Develop and present a recommended course of action to the F&A Committee
• Communicate final outcome to the provider (written and/or oral)
• Respond as needed to follow up internal and external inquires related to the case and case outcome@@Participate and lead provider site visits
• Initiates and coordinates referrals to law enforcement agencies, or state licensing boards, and if necessary, appears as a witness in cases brought to
• Participate in cross-department workgroups and committees@@Participate as an SIU representative and be able to articulate the SIU perspective
• Initiate cross department meetings and be able to communicate gaps or risks identified during an investigation or data analysis
• Participate in development and review of SIU Policies/Procedures and Desktops
• Actively participate in annual review of policies and procedures@@Document through desktop procedures process improvements

Skills:

• Ability to self-manage and work independently
• Strong interpersonal skills to enable an optimum working environment
• Working knowledge and understanding of the claims processing system
• Extensive knowledge of clinical coding guidelines and concepts including ICD-10, CPT-4, HCPCS, Revenue Codes and DRGs
• Knowledge of health care products, benefit policies, medical policies, and reimbursement policies
• Strong working knowledge of the Facets claims system

Knowledge:

• Must demonstrate strong critical thinking and problem-solving abilities
• Must demonstrate effective communication skills (written and oral) with the ability to clearly communicate complex issues both within and outside the organization.
• Ability to analyze data and look for patterns and anomalies
• Highly proficient in Microsoft Office products specifically Word and Excel with the ability to use basic Excel analytics tools (Pivot, formulas, filters etc.)

Experience:

• Five (5) years clinical experience in a healthcare setting
• Five (5) years’ experience in a health plan environment preferably in Utilization Management, Medical Claims Review or in data analytics or claims configuration environment.
• Experience conducting healthcare fraud investigations within a health plan or insurer setting preferred
• Experience in medical records reviews preferred

Education and Certifications:

• Active and unrestricted Pennsylvania Registered Nurse license, or advanced practice license.
• Certified Professional Coder (CPC) designation, or must successfully complete CPC designation within 24 months
• AHFI, CFE and/or other fraud designation preferred

Work Environment:

• Fast paced, with changing priorities with a need to adhere to various regulations and requirements.
• High degree of accuracy is required in all components of the job.

Physical Demands:

• While performing the duties of the job, the employee is frequently required to sit, use hands and fingers, talk, hear, and see.
• The employee must be able to work over 40 hours per week.
• The employee must occasionally lift and/or move up to 5 pounds.

Other:

• Occasional travel to attend offsite meetings.

About Us: We recognize that work is a part of life, not separate from it, and foster a flexible environment where your health and wellbeing are prioritized. At Capital you will work alongside a caring team of supportive colleagues and be encouraged to volunteer in your community. We value your professional and personal growth by investing heavily in training and continuing education, so you have the tools to do your best as you develop your career. And by doing your best, you’ll help us live our mission of improving the health and well-being of our members and the communities in which they live.