Investigative Auditor (45258)

The Investigative Auditor is responsible for the intake, triage, review, and documentation of Fraud, Waste, and Abuse (FWA) allegations referred to the Special Investigations Unit (SIU) team and conducts respective audits. Following an independent review of the allegations, the Investigative Auditor will determine whether to recommend closing referrals that lack sufficient supporting evidence or to advance the matter to an audit, as warranted by the initial findings.

This position may also monitor and analyze patterns of utilization and/or potentially fraudulent activities through prepayment claims reviews, post payment auditing and/or provider record review, ensuring claims, medical records and other documentation submitted to the company in relation to reimbursement are in compliance with all federal and state regulatory guidelines, contractual requirements and/or industry standards. Assists in the recovery of funds lost due to FWA and reports cases of suspected fraud to the Office of Program Integrity. Manages regulatory notices (HPMS memos), case summaries and coordinates with external entities, including but not limited to federal, state and local agencies and law enforcement. Works both independently and collaboratively with the SIU, and other business areas to ensure proper oversight of Neighborhood's FWA program and assists in identifying areas of non-compliance within the organization. Assists in the preparation of internal and external FWA reporting.

Duties and Responsibilities:

Responsibilities include but are not limited to:

• Respond to all allegations of potential Fraud Waste and Abuse (FWA). This includes: conduct intake, triage cases, and complete investigation of allegations of FWA activities involving members and providers.
• Analyze enrollment data, contract terms, financial records, provider and subscriber claims history, and other documentation to determine FWA and identify potential patterns. Apply regulatory and contractual requirements as well as internal policies and procedures to the case investigation process.
• Perform data analysis, research and review of claims data to identify trends, patterns, outliers and emerging issues in healthcare fraud, waste, and abuse with fraud technology.
• Perform prepayment claims review and post payment audits, as applicable.
• Research and investigate member Identity Theft cases through Member Service referrals. Investigate the potential of compromised member information as it relates to security breaches.
• Communicate with members and providers routinely regarding issues including investigative findings, recoveries, and educational feedback where appropriate.
• Maintain the integrity of documentation for FWA cases. Update tracking system to ensure documentation of all calls, evidence, referrals, inquiries and case events are accurate for record keeping purposes and for "Discovery" in court related cases.
• Establish and maintain strong relationships with external agencies including the Department of Health, Office of Inspector General, Federal Drug Enforcement, OPI, EOHHS, RI Attorney General, US Attorney and state/local law enforcement.
• Prepare data requests from external law enforcement agencies listed above as required.
• Develop clear and concise reports, present findings to providers and participate in negotiated resolution of issues at the direction of management. Track and report any claim adjustments, settlement agreements or payment plan agreements determined as result of investigation or court ordered restitution.
• Utilize findings to determine where there is a need for a change in policy and course of appropriate action based on line of business, severity of issue, regulatory compliance requirements and plan exposure. Drafts corrective action plans as appropriate.
• Performs other duties as assigned.

Qualifications

Required:

• Associate's degree in Health Information Management, Health Care Administration, Accounting/Finance, or a related field and two (2) or more years of experience conducting healthcare fraud, waste, and abuse (FWA) investigations and/or audits, or other healthcare-related audits within a Managed Care Organization; or, in lieu of a degree, three (3) or more years of experience conducting healthcare FWA investigations and/or audits within a Managed Care Organization
• Proven investigatory skills and ability to: organize, analyze, and determine risk with corresponding solutions while remaining objective and possessing the ability to separate facts from opinions
• Knowledge of Managed Care and Medicaid/Medicare program guidelines, medical terminology, anatomy and health care delivery systems
• Possess fundamental understanding of claim billing codes, CPT/HCPCS/ICD coding concepts, and healthcare billing concepts and data processing
• Proven ability to research and interpret regulatory requirements
• Effective interpersonal skills; ability to interact with individuals at all levels
• Excellent oral and written communication skills; presentation skills with ability to create and deliver training, informational and other types of programs
• Strong analytical, critical thinking, investigative, and problem-solving skills
• Ability to multi-task and operate effectively across geographic and functional boundaries
• Detail-oriented, self-motivated, able to meet tight deadlines
• Ability to develop realistic, motivating goals and objectives, track progress and adapt to changing priorities.
• Energetic and forward thinking with high ethical standards and a professional image
• Collaborative in nature and team oriented
• Advanced skills in Microsoft Office (Word, Excel, PowerPoint, Outlook), SharePoint and Intra/Internet as well as proficiency with incorporating/merging documents from various applications

Preferred:

• Bachelors degree
• Experience in medical records review, claims processing and/or utilization/case management in clinical practice
• National Health Care Anti-Fraud Association certification (AHFI), Certified Fraud Examiner (CFE) or America's Health Insurance Plans Health Care Anti-Fraud Associate (HCAFA) designation
• American Academy of Professional Coders (AAPC) or similar certification

Neighborhood Health Plan of Rhode Island is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.