Senior, Special Investigation Unit Investigator

Company Name:
## Description
Position Purpose: Investigate allegations of healthcare fraud and abuse activity. Assist in planning, organizing, and executing special claims investigations or audits that identify, evaluate and measure potential healthcare fraud.
Assist in monitoring business processes and systems to assure integrity and compliance in billing and claims payment
Investigate possible waste , abuse and fraud leads and document activity on each lead and refer issues to the appropriate party
Develop internal reports to identify potential waste, abuse and fraud
Perform data mining and analysis to detect aberrancies and outliers in claims
Serve as point of contact for corporate and field inquiries regarding waste, abuse and fraud
Review post-payment cases with appropriate parties to obtain refund
Provide case updates on progress of investigations and coordinate with Health Plans on recommendations and further actions and/or resolutions
Prepare summary and detailed reports on investigative findings for referral to Federal and State agencies
Arrange, conduct, and attend meetings with providers, business partners, and representatives from regulatory agencies and law enforcement regarding investigations
## Qualifications
Education/Experience: Bachelor's Degree in Business, Criminal Justice, Healthcare, related field or equivalent experience. 3+ years of medical claim investigation, medical claim audit, medical claim analysis, or fraud investigation experience. Knowledge of Microsoft Applications medical coding, claims processing, and data mining preferred.
Licenses/Certifications: Certified Professional Coder preferred
## Job
Job: Compliance
Primary Location: USA-Missouri-Chesterfield
Organization: Compliance SIU
Schedule: Full-time
Req ID: 1002061

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