Fraud Coordinator

Job ID: J121641
Company: Gateway Health Plan
Location: Pittsburgh, PA, United States
Full/Part Time: Full time
Job Type: Regular
Posted at: Apr 23, 2018

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Description

JOB SUMMARY

This job is responsible for assisting in the processing and investigation of non-complex health care claims to determine the legitimacy of claim charges.  The incumbent will also conduct or assist with provider and subscriber investigations to verify the validity of services and charges; will monitor internal referrals from sources such as claims, customer service, Medicare C&D Compliance, and Fraud Hotlines; will alert FIPR analysts of the need for further investigation; will perform claims system extracts and create reports, graphs and charts to support case documentation; will prepare necessary correspondence to set and monitor provider and member claim system flags; will work with external vendors to recover confirmed over payments; will participate in various internal committees as assigned; will update departmental tracking logs such as consultant listings and certified mail; and will input and maintain current case information in applicable case management tracking systems (FICO and FIMS).  Please note that the essential responsibilities listed below depend on the level of the position.

ESSENTIAL RESPONSIBILITIES

  • Claims Reviews/Investigation: Arrange for collection of claims and supporting data from internal and external sources including providers, customers and accounts; Review claims and supporting documentation to verify the legitimacy of medical and drug claim charges; Work with external vendors to recover confirmed hospital and ambulatory surgical center over-payments.
  • Fraud Waste and Abuse Audits/Findings: Assist in on-site investigations:  Assist in the interviews of customers and providers to obtain information in suspected fraud waste and abuse cases; Prepare reports and other information to document audit findings.
  • Calculate over-payments in established fraud cases.  Identify all fraudulent activity included in the case, determine what lines of business were involved in the fraudulent activity, and measure over-payment by means of sampling or complete review.
  • Data Analysis: Perform claims system extracts and create reports, graphs, and charts to support case documentation; Review reports and other information to identify claims and related documents requiring investigations based on pre-determined criteria, including review of suspect claims, Fraud Hot Line and internal referrals.
  • Update departmental tracking logs such as consultant listings, record request tracking, certified mail, etc…
  • Maintain current case related information on all applicable case management tracking systems such as FICO and FIMS.
  • Other duties as assigned or requested.

EDUCATION

Required

  • High School Diploma/GED

Preferred

  • Bachelor’s degree in Accounting, Finance, Business, Nursing or closely related field (Relevant work experience may be substituted for education on a year-for-year basis.  Relevant experience must be clearly defined.)

Experience

  • 3-5 years of relevant, progressive experience. Grandfathered experience requirements effective August 2016.
  • Healthcare fraud investigation experience, or healthcare experience

Preferred

  • Certified Professional Coder (CPC)
  • Knowledge of medical terminology
  • Experience in processing Blue Card, Local and FEP claims
  • Experience in working with SAS

SKILLS

  • Demonstrated proficiency in using Excel, Word, PowerPoint, and Access
  • Demonstrated strong multi-tasking and organizational skills
  • Demonstrated strong verbal and written communication skills
  • Demonstrated proficiency in using OSCAR, INSINQ, ICIS, and COR

SCOPE OF RESPONSIBILITY  

Does this role supervise/manage other employees?        

No 

  

WORK ENVIRONMENT

Is Travel Required?

No  

Unusual Working  Conditions

This position is responsible for clerical research, lower end audit procedures, and other support functions required within the department to maintain an efficient and timely flow of documents and testing necessary to assist co-workers and management in the performance of their responsibilities.

Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement: This position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
EEO is The Law
Equal Opportunity Employer Minorities/Women/ProtectedVeterans/Disabled/Sexual Orientation/Gender Identity (http://www1.eeoc.gov/employers/upload/eeoc_self_print_poster.pdf)
We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact number below.
For accommodation requests, please call HR Services at 844-242-HR4U or visit HR Services Online at HRServices@highmarkhealth.org

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