Analysis Skills, Auditing, Claims Processing, Continuous Improvement, Customer Support/Service, Data Analysis, Data Collection, Detail Oriented, Documentation Review, Establish Priorities, Interviewing Skills, Legal Standards, Maintain Compliance, Organizational Skills, Process Improvement, Regulations, Regulatory Compliance, Regulatory Requirements, Resolve Customer Issues, Strategic Planning, Training/Teaching
Job Summary:
Ensures the integrity and accuracy of claims processes and protocols. Collects data for audits/investigations into claims, utilizing a combination of analytical skills and attention to detail, reviewing documentation, interviewing involved parties, and communicating with various stakeholders to gather relevant information for successful resolution and closure. Identifies opportunities to target fraud, waste, and abuse or discrepancies in claims submissions. Adheres to industry regulations and policies for managerial follow-up. Analyzes data in order to effectively assess the validity of claims. Provides accurate recommendations to management for claim resolution and closure. Documents and inputs all findings, while preparing comprehensive reports that may be used for legal or audit/investigative purposes.
Essential Functions:
- Conducts routine and impartial audits/investigations from start to closure into customer claims, ensuring accurate and fair assessments of claims validity.
- Provides customer service by addressing inquiries and concerns, and escalates audit/investigation, as needed.
- Compiles detailed and organized records of audit/investigation findings, ensuring accuracy and compliance with legal and regulatory requirements.
- Applies functional knowledge to create and implement strategies to identify and prevent fraudulent activities, safeguarding the integrity of the claims process.
- Conducts interviews with relevant witnesses, claimants, and other stakeholders to gather additional information and perspectives on claims.
- Communicates with appropriate internal teams to ensure the proper processing of audits/investigations, while adhering to legal and regulatory standards.
- Communicates audit/investigation findings clearly and professionally to customers, claimants, and other stakeholders, managing expectations and providing updates.
- Assists in providing training and support to other auditors/investigators, contributing to the continuous improvement of investigative processes.
Level of Supervision Received:
Plans and arranges own work; works with manager to prioritize projects.
Education (can be substituted for experience):
Minimum Bachelor's Degree required
Work Experience (can be substituted for education):
2 - 4 years of experience required; 5 - 7 years preferred
Certification(s):
Certified Fraud Examiner preferred
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Qlarant Quality Solutions Inc