Responsible for conducting comprehensive review of claim data and/or medical record documentation related to Fraud Waste and Abuse (FWA) investigations opened by the Special Investigations Unit (SIU) from various internal and/or external sources. Position requires use of computer-based data mining tools, claim payment and case management systems to identify aberrant or potentially fraudulent billing patterns. The RN Clinical Auditor will obtain and review medical record documentation to validate authorized, billed and paid services were provided according to State and Federal regulations/guidelines, Neighborhood benefit coverage and payment policies, medical necessity and standards of care. This role works collaboratively with the entire SIU team and communicates with internal business areas as applicable related to the case as well as external State and Federal regulatory and law enforcement agencies as necessary.
Duties and Responsibilities:
• Plan and perform audits and investigations focused on detecting and preventing fraud waste and abuse utilizing knowledge of CPT, ICD, HCPS coding guidelines and regulations, benefit coverage, clinical medical and payment policies. • Utilize various data mining tools to proactively identify outliers and potential case leads. • Identify aberrant billing patterns resulting in overpayments or potential fraudulent activity. • Obtain and review medical record documentation to prepare comprehensive clinical review/investigative summaries per SIU Standard procedures. • Notify provider(s) of findings and provide feedback and education as necessary. Respond to appeals, prepare settlement agreements. • Prepare accurate reporting to recoupment staff to initiate recovery of overpayments. Refer to Legal department as necessary for assistance with recoveries from non-responsive providers. • Manage caseloads independently with attention to established timelines for casework ensuring timely follow up, audit completion and submission of recoupments and/or allegation of fraud to regulatory oversight agencies. • Maintain documentation of case work per SIU standard policies and procedures to support mandated reporting Core Contract reporting for EOHHS. • Work collaboratively with and providing case updates on progress of investigations to management, SIU and Compliance team members, internal business leads related to case and external agencies as necessary. • Communicate investigative findings and provide testimony in legal proceedings as required. • Assist with RFI's from external Regulatory and Law Enforcement agencies. • Assist with education on fraud and abuse awareness, detection and reporting to business areas as required. • Take responsibility for professional development, support a learning environment, and meet professional competency requirements. • Perform other duties as assigned
Corporate Compliance Responsibility:
As an essential function, responsible for complying with Neighborhood's Corporate Compliance Program, Standards of Business Conduct, applicable contracts, laws, rules and regulations, policies, and procedures as it applies to individual job duties, the department, and the Company. This position must exercise due diligence to prevent, detect, and report unlawful and/or unethical conduct by fellow co-workers, professional affiliates and/or agents.
Qualifications:
Required:
• Registered Nurse with an active, current, unrestricted license in RI in good standing • Minimum of three (3) years experience in healthcare coding directly related to determining appropriate diagnosis, procedure and other codes used in billing for services, utilization management, medical record auditing, or health care quality improvement • Knowledge of clinical medical record documentation requirements • A high-level knowledge of medical terminology • Proficient with various technology software tools, including Microsoft Office • Excellent written and verbal communication skills, and strong attention to detail • Ability to maintain confidentiality • Ability to take direction and support a multitude of individuals • Ability to work independently and prioritize activities
Preferred:
• Working knowledge of fraud, waste and abuse policies and practices • Evaluation and management coding and auditing expertise • Knowledge of Behavioral Health billing & coding guidelines and/or regulatory guidelines • Electronic medical record review experience • Electronic investigative case management and/or healthcare claims data mining tool experience. • Certified Coding Specialist (CCS), Certified Coding Specialist Provider-based (CCS-P), Certified Professional Coder (CPC or CPC-H), CPMA or equivalent certification. • Certified Fraud Examiner (CFE) or Accredited Healthcare Fraud Investigator (AHFI) certification
Neighborhood Health Plan of Rhode Island 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 veteran status
Neighborhood's employees come from a diverse background but all are committed to creating a more equitable health care system. Our array of experiences allows us to have a broad perspective and great creativity in facing whatever challenges arise. Unlike many other health insurance companies, we have nearly 30 nurses and social workers on staff. This structure speaks to our focus on active and compassionate care management for our members; we know that people who are alienated from the health care system require additional advocacy, outreach and support.
Neighborhood offers an exceptional compensation package to employees. We annually review base salaries/benefits and adjust as appropriate.