PH Clinical Investigator (Remote NC)

LOCATION:  Remote – must live in North Carolina or within 40 miles of the NC border. Must have ability to travel to the Asheville NC office as needed.

GENERAL STATEMENT OF JOB

The PH Clinical Investigator works under the direct supervision of the Special Investigations Director in the Compliance Department.  This position applies medical and behavioral health knowledge along with analytical skills to effectively and efficiently complete investigation and case consultation activities.  The PH Clinical Investigator is responsible for identifying and providing detailed reports of areas of incorrect coding, missing or insufficient documentation, suspected Medicaid fraud/waste/abuse, over utilization by providers, and ensuring providers meet medical necessity requirements.  They will interview witnesses and targets of investigations, participate in on-site provider reviews and coordinate investigations with internal and external partners as necessary.  The position will develop investigative summary reports and make applicable referrals to the NC Division of Health Benefits, and recommendations as necessary to providers associated with investigation findings/outcomes.  The PH Clinical  Investigator will provide medical guidance related to investigations and serve as the medical subject matter expert (SME) resource for the Special Investigations Unit.

ESSENTIAL JOB FUNCTIONS

Investigative Activities:

• Utilize established Vaya procedures to conduct inquiries and investigations into complaints, allegations, and referrals regarding suspected Fraud, Waste or Program Abuse of physical health services
• Review healthcare claims to determine if provider payments were rendered in accordance with rules, regulations, service definition, service utilization, and contractual requirements
• Determine correct coding, billing, documentation, delivery of services and potential violations of federal and/or state regulations or Medicaid guidelines
• Review clinical appropriateness of documentation and service delivery methodologies for potential fraudulent or abusive practices
• Perform investigative activities (desk review, virtual, and/or on-site), interview providers, members, and stakeholders, and review medical records to verify compliance with program policies and/or standards of healthcare, appropriateness of services or medical necessity
• Prepare reports and exhibits from the findings of provider investigations and develop recommendations or intervention strategies to correct or prevent abusive practices, including proposals to recover inappropriately paid monies or to suspend or terminate program participation
• File Ethics Complaints for licensed providers when indicated
• Refer suspected fraud cases to the DHB Office of Compliance and Program Integrity
• Serve as a physical health subject matter expert (SME) to team members and external stakeholders as needed
• Provide consultation and medical guidance to the Special Investigations Unit staff

Administrative Activities:

• Participate in both informal and formal appeal processes, defending their decisions before a Vaya appeal panel, hearing officers and administrative law judges
• Provide litigation testimony as applicable
• Work in conjunction with various regulatory bodies
• Propose new fraud prevention edits for automated claims/billing system when new fraudulent schemes are discovered

Support Activities:

• Other duties as assigned including technical assistance and provider education based upon need, area of expertise, special interests and availability of resources

KNOWLEDGE, SKILL & ABILITIES

• Knowledge of rules, regulations and contractual standards related to behavioral health and medical performance  methods and practices
• Knowledge of healthcare service definitions, service documentation, and service utilization requirements 
• Demonstrate proficiency in researching, understanding, interpreting and application of government rules/regulations/policies
• Knowledge of the application of medical necessity criteria and the ability to analyze the quality and necessity of healthcare services (inpatient and community based)
• Extensive oral and written communication with providers, state and federal regulatory agencies, licensing entities, independent contractors, and members 
• Excellent decision-making abilities to determine the appropriate course of action during investigations and subsequent follow-up
• Demonstrate strong attention to detail, precision and meticulous accuracy for all tasks
• Ability to establish appropriate and respectful relationships/partnerships with persons with a wide range of ethnicities and abilities
• Ability to organize priorities, perform multiple tasks concurrently and work efficiently with competing priorities   
• Excellent decision-making abilities based upon relevant facts and established processes to determine the appropriate course of action during an investigation and subsequent follow up 
• Exceptional interpersonal skills, ability to work with a team as well as autonomously, exercising sound judgment and problem resolution skills  
• Proficiency in Microsoft Office products (such as Word, Excel, Outlook, etc.)
• Knowledge of CPT, ICD and HCPCS coding

QUALIFICATIONS & EDUCATION REQUIREMENTS

Must be a Physician’s Assistant with a Master of Physician Assistant Studies Degree OR a Nurse with at minimum an Associate Degree in nursing. Incumbent must have at least two (2) years full-time experience with direct patient care clinical experience in the medical field.

Required licensure/certification:

• If a Nurse, then current unrestricted Active North Carolina RN License required; and if a Physician’s Assistant, then current unrestricted Active North Carolina PA License required.
• CLEAR-NCIT Basic Certified Investigator (CI) (should be obtained during first nine months of employment)

Preferred work experience:

• Experience in a hospital or clinical setting within the past 3 years preferred.
• Two (2) years’ experience with Healthcare/Health Plan preferred.
• Experience completing compliance reviews and preparing written reports preferred.

PHYSICAL REQUIREMENTS

• Close visual acuity to perform activities such as preparation and analysis of documents; viewing a computer terminal; and extensive reading. 
• Physical activity in this position includes crouching, reaching, walking, talking, hearing and repetitive motion of hands, wrists and fingers. 
• Sedentary work with lifting requirements up to 10 pounds, sitting for extended periods of time. 
• Mental concentration is required in all aspects of work.

RESIDENCY REQUIREMENT:  The person in this position is required to reside in North Carolina or within 40 miles of the North Carolina border.

SALARY: Depending on qualifications & experience of candidate. This position is exempt and is not eligible for overtime compensation. 

DEADLINE FOR APPLICATION: Open Until Filled

APPLY: Vaya Health accepts online applications in our Career Center, please visit https://www.vayahealth.com/about/careers/.

Vaya Health is an equal opportunity employer.