Overview
This role involves monitoring the processing and reconciliation of incoming electronic medical records, importing prepay claims and records, and generating operational reports related to the prepay claims process. The position supports research of prepay and post-pay record inquiries and manages the research and return of misdirected documents.
Responsibilities
- Monitor procedures, work instructions, and job aids related to quality management systems; provide first-level review for changes.
- Support problem-solving efforts for system issues.
- Provide expertise in implementing, deactivating, monitoring, quality assurance, and reporting of prepay edits.
- Facilitate meetings and coordinate presentations.
- Track and analyze data and reports to assess prepay committee edit effectiveness; create presentations.
- Assign and monitor completion of incoming and outgoing external contractor communications.
- Research prepay and post-pay record questions; report quality assurance findings for appeal requests, recalculations, and redeterminations.
- Schedule and coordinate ad hoc calls with external contractors or law enforcement; take meeting minutes.
- Review and comment on Medicare Joint Operating Agreements (JOAs).
- Create templates and content for external contractor annual fraud and abuse training.
Supervision
- Plans and arranges own work.
- Collaborates with manager to prioritize projects.
Requirements
- Minimum of a Bachelor's Degree (can be substituted with relevant experience).
- 2 to 4 years of experience required; 5 to 7 years preferred.
- Investigative experience required, preferably in healthcare.
- Experience in Special Investigations Unit (SIU), insurance company quality assurance, or fraud preferred.
Preferred Qualifications
- Certified Fraud Examiner (CFE) certification preferred.