Investigation Unit Analyst
Corewell Health
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Grand Rapids, MI, USA
Posted on Jul 27, 2024
Job Summary
Responsible for analyzing data to identify billing irregularities, trends and investigating fraud and abuse tips, and recovery opportunities. Investigations will include, but is not limited to, concerns involving members, providers, employer groups and agents. Performs substantive investigations and compliance audits in accordance with Priority Health guidelines, National Standards and regulatory agencies such as Medicare, Medicaid and MIChild. Documents findings and coordinate follow-up with internal and external representatives in order to correct practices and strengthen internal controls. This will include recovering payments where appropriate. Assist with internal and external education on fraud, waste, abuse, billing and documentations requirements.
Essential Functions
Examines random claims for compliance with relevant billing and processing guidelines and to identify opportunities for fraud and abuse prevention and control.
Review medical records for fraud, waste and abuse.
Conducts data mining activities and data analysis using available tools.
Performs compliance audits of medical claims, rate tables, fee screens, and other payment mechanisms to ensure accurate payment of financial obligations in accordance with corporate standards, policies and procedures and contractual arrangements and benefit design.
Conducts telephone and in-person interviews which may include members, providers, employer group, agents, etc. to determine validity of claims and allegations of fraud, waste and abuse. May also include conversations with law enforcement and regulatory agencies.
Coordinate corrective action if needed.
Investigate fraud and abuse tips received through the compliance hotline, customer service, and mail or identified through cost recovery projects.
Negotiate with providers for successful recoveries of funds.
How Corewell Health cares for you
Comprehensive benefits package to meet your financial, health, and work/life balance goals. Learn more here.
On-demand pay program powered by Payactiv
Discounts directory with deals on the things that matter to you, like restaurants, phone plans, spas, and more!
Optional identity theft protection, home and auto insurance, pet insurance
Traditional and Roth retirement options with service contribution and match savings
Qualifications
Required
Associate's Degree or two plus years of college credits preferable in a health, business, mathematics or statistics related degree or actively pursuing degree with 8 years of experience in medical claims (billing or payment), experience leading projects and experience educating billing guidelines.
3 years of relevant experience in detection, prevention, recovery and assisting in the prosecution of fraudulent activities in health-related business such as hospital/physician/pharmacy provider, audit, billing, compliance or health insurance.
Preferred
Bachelor's Degree with area of concentration in health related field or business.
Experience Knowledge of industry, claims, healthcare and medical terminology including understanding of CPT, ICD-9, HCPCS, APC and DRG's.
About Corewell Health
As a team member at Corewell Health, you will play an essential role in delivering personalized health care to our patients, members and our communities. We are committed to cultivating and investing in YOU. Our top-notch teams are comprised of collaborators, leaders and innovators that continue to build on one shared mission statement - to improve health, instill humanity and inspire hope. Join a nationally recognized health system with an ambitious vision of continued advancement and excellence.
Primary Location
SITE - Priority Health - 1231 E Beltline - Grand RapidsDepartment Name
PH - Special Investigations UnitEmployment Type
Full timeShift
Day (United States of America)Weekly Scheduled Hours
40Hours of Work
8 a.m. to 5 p.m.Days Worked
Monday to FridayWeekend Frequency
N/ACURRENT COREWELL HEALTH TEAM MEMBERS – Please apply through Find Jobs from your Workday team member account. This career site is for Non-Corewell Health team members only.
Corewell Health is committed to providing a safe environment for our team members, patients, visitors, and community. We require a drug-free workplace and require team members to comply with the MMR, Varicella, Tdap, and Influenza vaccine requirement if in an on-site or hybrid workplace category. We are committed to supporting prospective team members who require reasonable accommodations to participate in the job application process, to perform the essential functions of a job, or to enjoy equal benefits and privileges of employment due to a disability, pregnancy, or sincerely held religious belief.
Corewell Health grants equal employment opportunity to all qualified persons without regard to race, color, national origin, sex, disability, age, religion, genetic information, marital status, height, weight, gender, pregnancy, sexual orientation, gender identity or expression, veteran status, or any other legally protected category.
An interconnected, collaborative culture where all are encouraged to bring their whole selves to work, is vital to the health of our organization. As a health system, we advocate for equity as we care for our patients, our communities, and each other. From workshops that develop cultural intelligence, to our inclusion resource groups for people to find community and empowerment at work, we are dedicated to ongoing resources that advance our values of diversity, equity, and inclusion in all that we do. We invite those that share in our commitment to join our team.
You may request assistance in completing the application process by calling 616.486.7447.
This job is no longer accepting applications
See open jobs at Corewell Health.See open jobs similar to "Investigation Unit Analyst" Hello West Michigan.
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