Fraud Specialist

Where

Houston, TX

What you'll be doing

The client company is currently seeking for a fraud specialist. As a fraud specialist, candidate will collaborate with the benefits integrity unit manager to investigate instances of fraud, waste and abuse. Develop reports of investigation findings, compile accurate case file documentation, calculate overpayments, conduct and document interviews. Review and analyze investigation materials such as patient charts and claims data in conjunction with applicable regulations, contracts and policy manuals. Serve as a resource for departments to research, resolve integrity inquiries and abusive billing issues. Conduct data mining activities, data analysis using available tools and internal data warehouse. Develop audit rules and queries to pull data for potential FWA activity. Develop, maintain and manage BIU case tracking system. Identify and recommend policy, procedure and systems changes to enhance investigative outcomes and performance. Work cooperatively with other plan departments including provider relations, claims, finance and internal audit. Interface with providers, provider representatives and where appropriate, representatives from regulatory agencies. Update appropriate staff regularly on the progress of investigations and makes recommendations for further initiatives or closing the case. Work with external audit resource vendors on compliance audits and pharmacy audits to develop internal leads, track audits and investigative work. Work collaboratively with the BIU to look for cases in which member or prescriber fraud may interface with pharmacy fraud. Assist in the tracking, monitoring and reporting of pharmacy related cases of fraud, waste or abuse whether case development is internal or external.

What your background should be

The candidate must have at least 3 to 5 years of health insurance claims or compliance auditing experience. Claims related experience including strong working knowledge of coding, fee and reimbursement and claims processing policies and procedures. Previous state or federal regulatory, medicare advantage health plan compliance or investigation experience is preferred. Previous investigations experience, including report writing and interviewing and previous technical experience in fraud examiner protocols is also preferred. The applicant is should have strong oral and written communications skills; working knowledge of medical terminology and experience reviewing medical records.

Required Schooling / Training

Bachelor degree or equivalent is required.

Who is the client company

This is a global health insurance service company

If you are interested in this position, send your resume to apply@kochdavis.com