The Clinical Fraud Investigator Senior is responsible for identifying issues and/or entities that may pose potential risk associated with fraud and abuse. Conducts data mining activities using available tools and internal data warehouse. Performs comprehensive analysis and clinical evaluation of the collected data. Performs in-depth investigations on identified providers as warranted. Examines claims for compliance with relevant billing and processing guidelines and to identify opportunities for fraud and abuse prevention and control. Review and conducts analysis of claims and medical records prior to payment. Researches new healthcare related questions as necessary to aid in investigations. Collaborates with the Special Investigation Unit and other internal areas on matters of mutual concern. Recommends possible interventions for loss control and risk avoidance based on the outcome of the investigation. Coordinates with concerned unit/brand as appropriate regarding approved interventions such as recovery of overpayment, pre-payment audit of claims or putting providers on notice. Trains new associates. Develops, designs and implements new or revised methods to improve the CIU operations. This role requires associates be in the office 1-2 days per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of virtual work, promoting a dynamic and adaptable workplace. Alternate locations may be considered.
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