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Location: Charlestown, MA
Business Unit: Commonwealth Medicine
Department: Commonwealth Medicine - Benefits Coord. Consult. - W407612
Salary Grade: 46
Num. Openings: 1
Post Date: Jan. 15, 2019
GENERAL SUMMARY OF POSITION:
Under the general direction of the Associate Director, or designee, this position serves a crucial role in combating fraud, waste and abuse within the Medicaid program. This position provides clinical direction of cases/providers to identify potential aberrant billing patterns and performs all activities related to investigation of potential fraud, waste and abuse. In collaboration with colleagues, this position will perform clinical reviews based on federal and state regulations and be responsible to support findings and recovery efforts.
- Work as a team member to review medical documentation and records from a clinical perspective for potential Fraud, Waste and Abuse (FWA) and to identify trends in provider behavior and billing patterns, including potential overpayments.
- Analyze existing clinical audit practices and policies to define and ultimately implement changes to improve clinical integrity and overall unit processes.
- Act as a clinical resource to Investigator and Audit staff to help identify instances of FWA.
- Review Provider Disclosures to analyze reasons and apply logic to other providers to identify potential recoveries.
- Support Board of Hearing appeals, including assisting with preparation of cases and representing PCU at hearings.
- Apply in-depth knowledge of federal and state regulations and healthcare industry standards to assist in identifying potential fraud, waste and abuse.
- Conduct independent data mining and data analysis utilizing claims data to identify potential cases of FWA.
- Develop, maintain and manage cases in internal case tracking system as appropriate.
- Develop reports of investigative findings and issue findings in accordance with applicable regulations, policies and procedures.
- Provide assistance with the review of medical records and claims for other state agencies/vendors and serve as a resource to internal and external departments to research and resolve clinical integrity issues or findings.
- Review complaints and provide follow up action as applicable.
- As assigned, conduct onsite audits of providers.
- Participate in planning and implementation of Quality Improvement Projects for the program.
- Provide training/education of medical record reviews to staff to enhance clinical knowledge and integrity within the program.
- Maintain assigned work list and meet all regulatory and mandated turnaround times.
- Maintain positive working relationships with providers, peers, leadership, and state agencies.
- Participate in workgroups and performance improvement initiatives and demonstrate the use of quality improvement in daily operations.
- Perform other duties as required.
- Licensed RN
- 7 years of related experience in a clinical or healthcare claims setting.
- Previous experience conducting data mining in the healthcare industry, healthcare claim audits or other claims related experience.
- Knowledge of the law and regulations and it relates to fraud and fraud investigations
- Proficiency in Microsoft Office applications (Word, Excel, PowerPoint and Access).
- Excellent Customer service skills with the ability to interact professionally and effectively with providers, third party payers, and staff from all departments.
- Strong Interpersonal skills with the ability to work in a fast paced environment whether as a team member or an independent contributor.
- Strong oral and written communication skills including internal and external presentations.
- Bachelor's Degree in Nursing
- Individual possessing any of the following certifications or licensure: CFE, CPA, CPC, or CPMA.
- Strong knowledge of the Medicare and Medicaid Programs.
- Extensive experience reviewing medical records and claims for quality care assessments.
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