GENERAL SUMMARY
Responsible for identifying persons or organizations involved in suspicious claims activities. Conducts investigation of suspect claims. Maintains database/case files of abusive, fraudulent and/or potentially fraudulent claims. Participates in the recovery of wrongful payment to providers. Collects and prepares
evidence for referral to appropriate state/federal agency as mandated. Identifies and implements measures to prevent future payment of fraudulent/abusive providers.
ESSENTIAL RESPONSIBILITIES
- Retrospectively investigates and analyzes claims payments to detect fraudulent provider practices.
- Reviews and profiles individual providers as well as peer group billing behaviors.
- Prepares statistical and financial analysis to document findings.
- Creates detailed case reports of fraudulent and abusive payments to providers and subscribers.
- Obtains all data needed to assure compliance with regulatory agencies.
- Compiles statistics and sites CMS guidelines or other Federal or State requirements to defend analysis.
- Reports fraudulent claims to appropriate regulatory agencies as mandated.
- Recommends reimbursement and claim edits to Medical Directors, Provider Relations and Customer Service Organization.
- Clearly identifies and coordinates plan to recover inappropriate payments.
- Assists with development, modification and presentation of internal training program on the Fraud and Abuse Program.
- Performs other duties as required.
Qualifications:
JOB SPECIFICATIONS
Bachelor’s degree or equivalent experience.
Significant experience (usually 2+ years) in medical terminology, coding and claims handling.
Demonstrated ability to conduct and interpret quantitative/qualitative analysis.
Demonstrated ability to navigate among economic, clinical, research and technology disciplines.
Substantive knowledge of managed care operations. Strong clinical knowledge and skills.
Excellent written and verbal communication skills.
Able to work independently with minimal supervision.
Coventry Health Care is an Affirmative Action/Equal Opportunity Employer, and we are committed to building a talented and diverse team.
Job: Professionals
Primary Location: Rockville, MD, US
Organization: 42042 - FEHBP - Home Office
Schedule: Full-time
Job Posting: 2012-10-19 00:00:00.0
Job ID: 1211866