Offer summary

Qualifications:

Bachelor's degree preferred., 2+ years of fraud investigations and claims experience required., Strong analytical skills to evaluate claims data and identify suspicious patterns., Proficient in Microsoft Office and knowledge of healthcare coding conventions..

Key responsibilities:

Conduct preliminary investigations into allegations of fraud, waste, or abuse.

Analyze data to identify suspicious patterns and gather supporting documentation.

Organize and document investigative findings to support conclusions and recommendations.

Provide backup support to team members and complete required training sessions.

Job description

Our work matters. We help people get the medicine they need to feel better and live well. We do not lose sight of that. It fuels our passion and drives every decision we make.

Job Posting Title

SIU Specialist - Remote in the California market

Job Description

Responsible for the intake and initial handling of allegations of fraud, waste or abuse. Conducts preliminary investigation to assess the merit of an allegation through fact gathering and analysis of data. Uses independent judgment to conclude preliminary investigation in accordance with procedures or to present to management to recommend for audit or investigation. Serves as a corporate resource on fraud, waste and abuse issues and maintains confidentiality and compliance with HIPAA privacyrequirements and applicable state and federal regulations.

Responsibilities

FRAUD, WASTE AND ABUSE DETECTION:
- Maintains caseload of incidents with low to medium priority and complexity.
- Prioritize and manage workload to meet internal performance metrics, regulatory and contractual requirements.
- Analyze data to find suspicious patterns and outliers using knowledge of healthcare coding conventions, fraud schemes, and general areas of vulnerability.
- Contact referrer, member, provider, or witnesses to gather additional information, facts and supporting documentation.
- Collaborate and refer non-SIU related issue and activities to external departments (Cost Containment, Networks, Clinical) for handling.
PACKAGING OF FINDINGS AND RECOMMENDATIONS:
- Organize data and document preliminary investigative steps with a high level of detail and accuracy, to clearly and concisely support conclusions and recommendations.
MISCELLANEOUS DUTIES:
- Provide backup support to team members (SIU Coordinator and Senior SIU Specialist) in the performance of job duties as assigned.
- Successfully complete required training sessions and continuing education credits.
- Other duties as assigned.

Education & Experience

Education Level Bachelors

Experience Level 2+ years
Required Fraud Investigations and Claims experience

Must be eligible to work in the United States without the need for work visa or residency sponsorship.

Additional Qualifications

3+ years' fraud investigations/claims experience.
Ability to manage workload while simultaneously working on multiple projects and cases with timely and accurate results with limited supervision.
Demonstrated strategic and analytical abilities to review and evaluate information such as claims data, suspicious patterns and other supporting information related to case allegation.
Requires the verbal, written and interpersonal skills to effectively interact and communicate conclusions and recommendations to management and customers.
Proficient with Microsoft Office Word, Excel and PowerPoint with ability to quickly learn and use new software applications.
Knowledge of ICD-9/10, CPT/HCPS/Revenue codes, insurance terms and policy interpretation.
CFE - Certified Fraud Examiner credential preferred.
Bachelor’s degree preferred.
Prefer knowledge of managed health care business model and processes, preferably in behavioral health, radiology or pharmacy.

Preferred Qualifications

Physical Demands

Must be able to remain in a stationary position 50% of the time. Must be able to "move or traverse"
Must be able to constantly operate a computer and/or other office productivity equipment
Must be able to hear and constantly communicate information and ideas. Must be able to exchange accurate information
Occasionally required to lift and/or move up to 10 pounds and occasionally lift and/or move up to 25 pounds

Every employee must understand, comply with and attest to the security responsibilities and security controls unique to their job, and comply with all applicable legal, regulatory, and contractual requirements and internal policies and procedures.

Potential pay for this position ranges from $21.15 - $31.73 based on experience and skills.

To review our Benefits, Incentives and Additional Compensation, visit our Benefits Page and click on the "Benefits at a glance" button for more detail.

Prime Therapeutics LLC is proud to be an equal opportunity and affirmative action employer. We encourage diverse candidates to apply, and all qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sex (pregnancy, sexual orientation, and gender identity), national origin, disability, age, veteran status, or any other legally protected class under federal, state, or local law.   

We welcome people of different backgrounds, experiences, abilities, and perspectives including qualified applicants with arrest and conviction records and any qualified applicants requiring reasonable accommodations in accordance with the law.

Prime Therapeutics LLC is a Tobacco-Free Workplace employer.

Positions will be posted for a minimum of five consecutive workdays.

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