Investigations Coordinator

Company :

Job 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 Investigators of the need for further analysis; 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, coordinate payment of vendor invoices and coordinate request for an independent review determination ; will participate in various internal committees as assigned; will update departmental tracking logs such as consultant listings, provider/member flag tracker and certified mail; and will input and maintain current case information in applicable case management tracking systems.

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 facility and professional provider over-payments.
• Investigation Support: Assist with 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, waste and abuse cases. Identify all suspect activity included in the case, determine what lines of business were involved in the suspect 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, provider/member flag tracking, record request tracking, vendor related, certified mail, etc.
• Maintain current case related information on all applicable case management tracking systems.
• Set and update member flags and monitor claims that suspend due to the flag.
• Other duties as assigned or requested.
  

EDUCATION

Required

• Associate's Degree

Substitutions

• 3 years of related and progressive experience in lieu of Associate's degree
  

Preferred

• None

EXPERIENCE

Required

• 3 years in Healthcare, Finance, provider office or related industry
  

Preferred

• Experience in processing Blue Card, Local and FEP claims
• Experience in working with SAS
  

LICENSES or CERTIFICATIONS

Required

• None
  

Preferred

• Certified Professional Coder (CPC)
  

SKILLS

• Demonstrated proficiency in using Excel and Word
• Knowledge of medical terminology
• Demonstrated strong multi-tasking and organizational skills
• Demonstrated strong verbal and written communication skills
• Demonstrated proficiency in using OSCAR, INSINQ, ICIS, and COR or experience with other claims related processing platforms
  

Language (Other than English):

None

Travel Requirement:

0% - 25%

PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS

Position Type

Office-based

Teaches / trains others regularly

Occasionally

Travel regularly from the office to various work sites or from site-to-site

Rarely

Works primarily out-of-the office selling products/services (sales employees)

Never

Physical work site required

Yes

Lifting: up to 10 pounds

Constantly

Lifting: 10 to 25 pounds

Occasionally

Lifting: 25 to 50 pounds

Rarely

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 job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.

As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy.

Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.

Pay Range Minimum:

Pay Range Maximum:

Base pay is determined by a variety of factors including a candidate’s qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations. The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets.

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, age, 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, age, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.

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