Job Summary

Performs activities related to the detection and investigation of fraud and abuse within Priority Health. Utilizes knowledge/expertise of health care fraud to investigate all types of health care fraud including member, employer group, agent, pharmacy, provider, etc. Investigates, collects and documents findings for management review. Investigation may include research, interviews, data analysis, and substantive desk or onsite medical record review. Responsible for preparing case file, final report and ensuring corrective action is taken if applicable. Assists with internal and external education on fraud, waste, abuse, billing and documentations requirements.

Essential Functions

Responsible for investigating, collecting, researching data to detect fraudulent or abusive practices by utilizing system tools, interviews, medical records audits, data mining, perform compliance audits of medical claims, fee screens and other payment mechanism to ensure accurate payment.

Investigate fraud and abuse tips received through the compliance hotline, internal referral or identify through data analytics. Support information requests my government agencies, law enforcement, external auditors, etc. Conduct telephone and in person interviews which may include members, providers, employer group agents etc. to determine validity of allegations of fraud waste and abuse. May include conversations with law enforcement and regulatory agencies.

Prepare financial analyses and reports to document finding and maintain up to date case files. Case files to include documentation to substantiate investigative process, findings, final report. In addition, notifications of finding letter for dissemination to provider or affected entity, notification letters to regulatory agencies if applicable. Presents provider offers for settlement to management and legal for approval.

Responsible for understanding plan documents, provider and agent agreements, products offered, State and Federal laws related to fraud, waste or abuse, Medicare and Medicaid regulations, etc.

Ability to work effectively with minimal supervision and direction and exhibit good problem-solving skills.

Assists in training of fraud awareness for members, providers, employer groups, agents and vendors.

Qualifications

Required

Bachelor's Degree or equivalent Health, Business or statistics

2 years of relevant experience Detection, prevention and recovery related to abusive and fraudulent practices related to hospital, physician, pharmacist pharmacy, employer group, agent or other fraudulent entity.

2 years of relevant experience Related health care experience

One of the following certifications is required:

CRT-Registered Health Information Technician (RHIT) - AAPC American Academy of Professional Coders Upon Hire  

CRT-Registered Health Information Administrator (RHIA) - AHIMA American Health Information Management Association Upon Hire

CRT-Professional Coder - AAPC American Academy of Professional Coders Upon Hire

CRT-Professional Coder, Certified - Payer (CPC-P) - UNKNOWN Unknown Upon Hire

CRT-Outpatient Coder, Certified (COC) - UNKNOWN Unknown Upon Hire

CRT-Coding Specialist (CCS) - AHIMA American Health Information Management Association Upon Hire

CRT-Coding Specialist, Certified-Physician Based (CCS-P) - AHIMA American Health Information Management Association Upon Hire

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.

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

Eligibility for benefits is determined by employment type and status

Primary Location

SITE - Priority Health - 1231 E Beltline - Grand Rapids

Department Name

PH - Special Investigations Unit

Employment Type

Full time

Shift

Day (United States of America)

Weekly Scheduled Hours

40

Hours of Work

8:00 a.m. to 5:00 p.m.

Days Worked

Monday to Friday

Weekend Frequency

N/A

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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.