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SIU Investigator

Coventry Health Care, a $12.2 billion Fortune 500 organization, is a national managed health care company with nearly 5.1 million members in all 50 states. At Coventry Health Care, we are driven to ensure that every person and organization we serve receives the greatest possible value for their health care investment. We do this by providing a full range of competitive products through our seven core businesses – Commercial Risk, Medicare Advantage, Medicare Part D, Medicaid, Workers' Comp Services, Federal Employees Health Benefits Plan and Network Rental.

We are committed to constantly improving our low-cost platform so that we can deliver the products and services that our customers want at a price they can afford. Coventry has the expertise, the experience, and the agility to craft the new products, the new processes, and the new service needed to make healthcare more accessible to all Americans.

Our national managed care company is seeking a SIU Investigator in our Louisville, KY Service Center. As a strategic member of the Customer Service Operations (CSO) team, the successful candidate will be responsible for identifying persons or organizations involved in suspicious claims activities, conducting investigations of suspect claims, and participating in the recovery of wrongful payment to providers, as well as collecting & preparing evidence for referral to appropriate state/federal agency.

We offer a competitive salary, excellent benefits (401K with company matching, comprehensive benefits including medical, dental, and tuition reimbursement), vacation and sick time. This is a highly visible role dealing with business partners across the division and corporation, and being a part of motivating a dynamic team!

ESSENTIAL RESPONSIBILITIES:

·         Investigate and analyze claims payments to detect fraudulent provider practices.

·         Review and profile individual providers as well as peer group billing behaviors.

·         Prepare statistical and financial analysis to document findings.

·         Create detailed case reports of fraudulent and abusive payments to providers and subscribers.

·         Obtain all data needed to assure compliance with regulatory agencies.

·         Compile statistics and site CMS guidelines or other Federal or State requirements to defend analysis.

·         Make recommendations regarding claim payment and provider participation to Medical Directors, Provider Relations, and Customer Service Organization.

·         Refer cases to the Recovery Department for processing.