manager, special investigations unit (siu) - p&c Jobs in Arizona

manager, special investigations unit (siu) - p&c

injury examiner

special investigator

USAA

Why USAA?At USAA, our mission is to empower our members to achieve financial security through highly competitive products, exceptional service and trusted advice. We seek to be the choice for the military community and their families.Embrace a fulfilling career at USAA, where our core values - honesty, integrity, loyalty and service - define how we treat each other and our members. Be part of what truly makes us special and impactful.The OpportunityWe are looking for a Manager, SIU (Special Investigations Unit) within P&C. Responsible for operational management of Claims fraud investigative teams. Directs staff in the investigation of cases involving questionable, suspect, or fraudulent activity. Ensures compliance with policies and procedures contributing to fraud control objectives, as well as compliance with state insurance fraud-related laws and regulations.This role is remote eligible in the continental U.S. with occasional business travel.What you'll do:<ul><li>Responsible for insurance fraud detection and investigation services to reduce fraud-related claim payments and costs, while avoiding unwarranted risk.</li><li>Ensures compliance with laws and regulations relating to claims handling and unfair claims practices and reporting statutes.</li><li>Participates in the establishment and implementation of policies and procedures for fraud control and investigative practices.</li><li>Performs leadership and management tasks, i.e., providing coaching, evaluating performance, review of time sheets, managing time off, conducting quarterly check-ins/ride-alongs, etc.</li><li>Evaluates, authorizes, and implements actions and decisions to carry out proactive claim's projects and investigations.</li><li>Reviews and evaluates investigation recommendations from investigators to ensure results and case documentation support conclusions.</li><li>Ensures risks associated with business activities are effectively identified, measured, monitored, and controlled in accordance with risk and compliance policies and procedures.</li></ul>What you have:<ul><li>Bachelor's degree; OR 4+ years of related experience (in addition to the minimum years of experience required) may be substituted in lieu of degree.</li><li>6+ years P&C industry functional work experience OR 4+ years of P&C experience plus military service experience.</li><li>2+ years of demonstrated leadership experience, supervisory or management experience.</li><li>Extensive knowledge and experience in all levels of claims investigation or fraud investigation and regulatory reporting requirements.</li><li>Knowledge of anti-fraud analytics programs as it relates to fraud prevention and identification.</li><li>Thorough understanding of investigative tools and techniques to guide and coach special investigators.</li><li>Demonstrated ability to build and maintain collaborative relationships with internal and external partners and business areas.</li><li>Demonstrated management skills and the ability to demonstrate monthly productivity and cycle time outcomes from investigations assigned to the SIU team.</li><li>Ability to prepare and present training sessions and case outcomes.</li><li>Demonstrated experience facilitating and managing projects and teams.</li></ul>What sets you apart:<ul><li>Demonstrated expertise in process design, risk assessment, and implementation of internal controls to mitigate fraud and other risks.</li><li>4+ years of progressive experience within a Special Investigations Unit (SIU), with a proven track record in process ownership and/or leadership roles.</li><li>Direct experience handling or managing investigations related to internal fraud, including developing investigative strategies and implementing preventative measures.</li><li>Proven ability to create engaging training content and deliver compelling presentations to diverse audiences, including investigators, management, and other stakeholders.</li><li>Exceptional business acumen and communication skills, with the ability to effectively articulate complex issues, identify gaps and opportunities within the SIU, and present recommendations to stakeholders across the organization in a clear and persuasive manner.</li><li>US military experience through military service or a military spouse/domestic partner</li></ul>Compensation range: The salary range for this position is: $114,080 - $218,030.USAA does not provide visa sponsorship for this role. Please do not apply for this role if at any time (now or in the future) you will need immigration support (i.e., H-1B, TN, STEM OPT Training Plans, etc.). Compensation: USAA has an effective process for assessing market data and establishing ranges to ensure we remain competitive. You are paid within the salary range based on your experience and market data of the position. The actual salary for this role may vary by location. Employees may be eligible for pay incentives based on overall corporate and individual performance and at the discretion of the USAA Board of Directors. The above description reflects the details considered necessary to describe the principal functions of the job and should not be construed as a detailed description of all the work requirements that may be performed in the job. Benefits: At USAA our employees enjoy best-in-class benefits to support their physical, financial, and emotional wellness. These benefits include comprehensive medical, dental and vision plans, 401(k), pension, life insurance, parental benefits, adoption assistance, paid time off program with paid holidays plus 16 paid volunteer hours, and various wellness programs. Additionally, our career path planning and continuing education assists employees with their professional goals. For more details on our outstanding benefits, visit our benefits page on Applications for this position are accepted on an ongoing basis, this posting will remain open until the position is filled. Thus, interested candidates are encouraged to apply the same day they view this posting. USAA is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.

Manager, Special Investigations Unit (SIU) - P&C

Why USAA?At USAA, our mission is to empower our members to achieve financial security through highly competitive products, exceptional service and trusted advice. We seek to be the choice for the military community and their families.Embrace a fulfilling career at USAA, where our core values - honesty, integrity, loyalty and service - define how we treat each other and our members. Be part of what truly makes us special and impactful.The OpportunityWe are looking for a Manager, SIU (Special Investigations Unit) within P&C. Responsible for operational management of Claims fraud investigative teams. Directs staff in the investigation of cases involving questionable, suspect, or fraudulent activity. Ensures compliance with policies and procedures contributing to fraud control objectives, as well as compliance with state insurance fraud-related laws and regulations.This role is remote eligible in the continental U.S. with occasional business travel.What you'll do:<ul><li>Responsible for insurance fraud detection and investigation services to reduce fraud-related claim payments and costs, while avoiding unwarranted risk.</li><li>Ensures compliance with laws and regulations relating to claims handling and unfair claims practices and reporting statutes.</li><li>Participates in the establishment and implementation of policies and procedures for fraud control and investigative practices.</li><li>Performs leadership and management tasks, i.e., providing coaching, evaluating performance, review of time sheets, managing time off, conducting quarterly check-ins/ride-alongs, etc.</li><li>Evaluates, authorizes, and implements actions and decisions to carry out proactive claim's projects and investigations.</li><li>Reviews and evaluates investigation recommendations from investigators to ensure results and case documentation support conclusions.</li><li>Ensures risks associated with business activities are effectively identified, measured, monitored, and controlled in accordance with risk and compliance policies and procedures.</li></ul> What you have: <ul><li>Bachelor's degree; OR 4+ years of related experience (in addition to the minimum years of experience required) may be substituted in lieu of degree.</li><li>6+ years P&C industry functional work experience OR 4+ years of P&C experience plus military service experience.</li><li>2+ years of demonstrated leadership experience, supervisory or management experience.</li><li>Extensive knowledge and experience in all levels of claims investigation or fraud investigation and regulatory reporting requirements.</li><li>Knowledge of anti-fraud analytics programs as it relates to fraud prevention and identification.</li><li>Thorough understanding of investigative tools and techniques to guide and coach special investigators.</li><li>Demonstrated ability to build and maintain collaborative relationships with internal and external partners and business areas.</li><li>Demonstrated management skills and the ability to demonstrate monthly productivity and cycle time outcomes from investigations assigned to the SIU team.</li><li>Ability to prepare and present training sessions and case outcomes.</li><li>Demonstrated experience facilitating and managing projects and teams.</li></ul> What sets you apart: <ul><li>Demonstrated expertise in process design, risk assessment, and implementation of internal controls to mitigate fraud and other risks.</li><li>4+ years of progressive experience within a Special Investigations Unit (SIU), with a proven track record in process ownership and/or leadership roles.</li><li>Direct experience handling or managing investigations related to internal fraud, including developing investigative strategies and implementing preventative measures.</li><li>Proven ability to create engaging training content and deliver compelling presentations to diverse audiences, including investigators, management, and other stakeholders.</li><li>Exceptional business acumen and communication skills, with the ability to effectively articulate complex issues, identify gaps and opportunities within the SIU, and present recommendations to stakeholders across the organization in a clear and persuasive manner.</li><li>US military experience through military service or a military spouse/domestic partner</li></ul>Compensation range: The salary range for this position is: $114,080 - $218,030.USAA does not provide visa sponsorship for this role. Please do not apply for this role if at any time (now or in the future) you will need immigration support (i.e., H-1B, TN, STEM OPT Training Plans, etc.). Compensation: USAA has an effective process for assessing market data and establishing ranges to ensure we remain competitive. You are paid within the salary range based on your experience and market data of the position. The actual salary for this role may vary by location. Employees may be eligible for pay incentives based on overall corporate and individual performance and at the discretion of the USAA Board of Directors. The above description reflects the details considered necessary to describe the principal functions of the job and should not be construed as a detailed description of all the work requirements that may be performed in the job. Benefits: At USAA our employees enjoy best-in-class benefits to support their physical, financial, and emotional wellness. These benefits include comprehensive medical, dental and vision plans, 401(k), pension, life insurance, parental benefits, adoption assistance, paid time off program with paid holidays plus 16 paid volunteer hours, and various wellness programs. Additionally, our career path planning and continuing education assists employees with their professional goals. For more details on our outstanding benefits, visit our benefits page on Applications for this position are accepted on an ongoing basis, this posting will remain open until the position is filled. Thus, interested candidates are encouraged to apply the same day they view this posting. USAA is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.

Molina Healthcare

<div>
 
 Job Description
 
 
 
 
 Job Summary
 
 
 
 The Medical Claim Review Nurse provides support for medical claim review activities. Responsible for ensuring timely claims payment processes, providing counsel to members regarding coverage and benefit interpretation, and appropriate level of care for provision of member services in alignment with state, federal, accrediting, and billing/coding guidelines and regulations. Contributes to overarching strategy to provide quality and cost-effective member care.
 
 
 For this position we are seeking an RN with previous Inpatient Hospital, Skilled Nursing Facility experience, and outpatient coding experience including diagnosis. Candidates with knowledge of CPT/HCPCS codes, record review, chart audit, provider disputes, appeals, and 1500 &amp; UB04 claim experience are highly preferred. Ability to apply state and federal regulations based on specific state and line of business. Must be able to work in a fast paced environment with frequent updates to reviews and processes. Further details to be discussed during the interview process.
 
 
 Remote position
 
 
 Work hours: Monday - Friday 8:00am - 5:00pm.
 
 
 
 Essential Job Duties
 
 
 
 <ul>
 <li>
 Performs clinical/medical reviews of retrospective medical claim reviews, medical claims and previously denied cases in which an appeal has been submitted, to ensure medical necessity and appropriate/accurate billing and claims processing.
 </li>
 <li>
 Validates member medical records and claims submitted/correct coding to ensure appropriate reimbursement to providers.
 </li>
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 Identifies and reports quality of care issues.
 </li>
 <li>
 Assists with complex claim review including diagnosis-related group (DRG) validation, itemized bill review, appropriate level of care, inpatient readmission, and any opportunity identified by the payment Integrity analytical team; makes decisions and recommendations pertinent to clinical experience.
 </li>
 <li>
 Facilitates document management, clinical reviews, bill audit findings and audit details in the database.
 </li>
 <li>
 Provides supporting documentation management for denial and modification of payment decisions.
 </li>
 <li>
 Independently re-evaluates medical claims and associated records by applying advanced clinical knowledge, knowledge of all relevant and applicable federal and state regulatory requirements and guidelines, knowledge of Molina policies and procedures, and individual judgment and experience to assess the appropriateness of service provided, length of stay and level of care.
 </li>
 <li>
 Reviews medically appropriate clinical guidelines and other appropriate criteria with medical directors on denial decisions.
 </li>
 <li>
 Supplies criteria supporting all recommendations for denial or modification of payment decisions.
 </li>
 <li>
 Serves as a clinical resource for utilization management, chief medical officers, physicians and member/provider inquiries/appeals.
 </li>
 <li>
 Provides training and support to clinical peers.
 </li>
 <li>
 Identifies and refers members with special needs to the appropriate Molina program per applicable policies/protocols.
 </li>
 <li>
 Collaborates and/or leads special projects.
 
 
 </li>
 </ul>
 
 Required Qualifications
 
 
 
 <ul>
 <li>
 At least 2 years clinical nursing experience, preferably in a hospital setting, including at least 1 year of utilization review, medical claims review, claims auditing, medical necessity review and/or coding experience, or equivalent combination of relevant education and experience.
 </li>
 <li>
 Registered Nurse (RN). License must be active and unrestricted in state of practice.
 </li>
 <li>
 Experience working within applicable state, federal, and third-party regulations.
 </li>
 <li>
 Strong analytic and problem-solving abilities.
 </li>
 <li>
 Strong organizational and time-management skills.
 </li>
 <li>
 Ability to multi-task and meet deadlines.
 </li>
 <li>
 Attention to detail.
 </li>
 <li>
 Critical-thinking and active listening skills.
 </li>
 <li>
 Common look proficiency.
 </li>
 <li>
 Decision-making and problem-solving skills.
 </li>
 <li>
 Strong verbal and written communication skills.
 </li>
 <li>
 Microsoft Office suite/applicable software program(s) proficiency, and ability to learn new programs.
 
 
 </li>
 </ul>
 
 Preferred Qualifications
 
 
 
 <ul>
 <li>
 Certified Clinical Coder (CCC), Certified Medical Audit Specialist (CMAS), Certified Case Manager (CCM), Certified Professional Healthcare Management (CPHM), Certified Professional in Healthcare Quality (CPHQ) or other health care certification.
 </li>
 <li>
 Nursing experience in critical care, emergency medicine, medical/surgical or pediatrics.
 </li>
 <li>
 Billing and coding experience.
 
 
 </li>
 </ul>
 To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board.
 
 
 Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V
 
 
 Pay Range: $26.41 - $61.79 / HOURLY
 
 
 <ul>
 <li>
 Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
 </li>
 </ul>
</div>

RN Medical Claim Review Nurse Remote

Explore 43+ Special investigator in Arizona this November. Find roles across top companies and apply now to boost your career.

43 special investigator jobs IN Arizona

Manager, Special Investigations Unit (SIU) - P&C

Manager, Special Investigations Unit (SIU) - P&C

Manager, Special Investigations Unit (SIU) - P&C

Manager, Special Investigations Unit (SIU) - P&C

Manager, Special Investigations Unit (SIU) - P&C

Manager, Special Investigations Unit (SIU) - P&C

RN Medical Claim Review Nurse Remote