- Molina Healthcare (Covington, KY)
- …responsible to lead a small team of investigators and provide oversight on daily investigative activities as a back-up to the SIU Manager. This position will be ... integrity programs. The position must have the ability to determine correct coding , documentation, potential fraud, abuse, and over utilization by providers and… more
- UPMC (Pittsburgh, PA)
- …and investigations highly preferred. Under the direction of the manager, the Special Investigations Unit (SIU) Investigator is responsible for investigating ... Health Plan has an exciting opportunity for a SIU Investigator ! This is a remote, full-time role working daylight...maintaining the FWA case system with accurate and detailed investigative activities related to assigned cases. Responsibilities: - … more
- Point32Health (Canton, MA)
- …more about who we are at Point32Health (https://www.point32health.org/) . **Job Summary** The Investigator I is an essential team member of the Special ... and abuse, and developing action plans to address the investigative findings and prevent future loss. This role will...the direction of the Manager, FWA Prepayment Review. The Investigator I works closely with other members of the… more
- Highmark Health (Pittsburgh, PA)
- …be conducted onsite or offsite. This incumbent is also responsible for the field investigative work necessary to complete a review of a special project, ... closure of the case. Conduct audits for proactive and investigative purposes to comply with internal audit and regulatory...other individual(s) necessary to complete a case review or special project. Determines the scope of the allegation or… more
- Highmark Health (Harrisburg, PA)
- …be conducted onsite or offsite. The incumbent is also responsible for the field investigative work necessary to complete a review of a special project, potential ... agencies through closure of the case. Conduct audits for proactive and investigative purposes to comply with internal audit and regulatory requirements. **ESSENTIAL… more
- Centene Corporation (Frankfort, KY)
- …compliance and fraud, waste, and abuse related matters; while maintaining an investigative workload of moderate to high complexity. Assists manager on monitoring ... while meeting all regulatory, CMS, and WellCare Corporate guidelines in which special care is required to protect and enhance WellCare's reputation. + Works… more
- MVP Health Care (Schenectady, NY)
- …investigation experience involving economic or insurance relatedmatters. + A clinical investigator must have in addition to the above requirements: A duly ... + Obtain CPC and/or COC credential. + Maintain nursing license and coding credentials through continuing education process as required. + Superior judgment skills,… more
- CareFirst (Baltimore, MD)
- …pay or deny a claim or claim lines using clinical and/or coding , billing, or reimbursement knowledge. Maintain appropriate records and supporting documentation ... within departmental and communicated timelines. + Provide support to investigative teams as they perform all levels of healthcare...or potential fraud by health care providers/facilities. + Perform special projects to meet the objectives of the … more
- Centene Corporation (Harrisburg, PA)
- …behavioral health care, laboratory, etc. Provides investigative support to the Special Investigations Unit (SIU) related to coding and billing issues and ... with investigators to identify abuse and fraud by utilizing clinical and coding expertise to analyze patterns in billing activities. + Performs other duties… more
- BlueCross BlueShield of North Carolina (NC)
- **Job Description** The AVP Special Investigations Unit (SIU) is responsible for overseeing and managing fraud, waste, and abuse (FWA) detection, investigation, and ... role involves leading a matrixed team of investigators, analysts, and clinical/ coding subject matter experts, working closely with internal and external stakeholders… more
- The County of Los Angeles (Los Angeles, CA)
- …in the master key system. Establishes, expands, and modifies master key coding systems. Issues keys and locks and keeps related distribution records. Operates ... objects weighing over 25 pounds, and frequent lifting of 10-25 pounds. SPECIAL REQUIREMENT INFORMATION *Journey-level experience applies to a person who has… more
- Mount Sinai Health System (New York, NY)
- …and physician leadership, this position works closely with Revenue Integrity, Coding , Billing, Cash Posting, and Case Management in defining vision, strategy ... resolves conflicts regarding public accounting firms, third-party auditors, and investigative parties. + Fiduciary responsibility for ensuring that compliance… more