Compliance Analyst - Baltimore, United States - KMM Technologies

Description

Job Description

Job Description

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Position

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Regulatory Compliance Analyst


Location:
Baltimore, MD


Duration:
Long Term


Job Description :
The role of the Special Investigations Unit (SIU) Investigator is to assist in the reduction and recuperation of losses through the detection, investigation, and resolution of low to medium levels fraud, waste, and abuse schemes, resulting in the savings and recovery of funds

Independently conduct low to medium level investigations and provide support as part of an assigned team to all levels (low to medium) investigations of suspected fraud, waste, and abuse.

Initiate claim adjustments, voucher deducts, and voluntary refunds in order to recover funds. Record recoveries and savings following established processes.

Required Qualifications :

Education Level:
Bachelor's Degree

Experience:
4 years insurance, investigative, health care, nursing or law enforcement.
Experience in claim adjustments, voucher deducts, and voluntary refunds in order to recover funds. Recording recoveries and savings following established processes.
Credential in a health care or investigations related area such as Certified Fraud Examiner (CFE),
Accredited Health Fraud Investigator (AHFI), RN/LPN, or Certified Professional Coder (CPC).

Knowledge of ICD 10 and CPT Codes, medical terminology, extensive training in claims and subscriber customer service methods, and previous experience in the health care industry.

Knowledge of laws that pertain to public and insurance funds - Proficient
Excellent communication skills both written and verbal. - Proficient
Ability to recognize, analyze, and solve a variety of problems. - Proficient
Ability to maintain effective interpersonal relationships - Proficient

Responsibilities :
Perform special projects as assigned by management to meet the needs of the Special Investigations Unit.
In conjunction with assigned team or management, develop and execute investigative plans that may include performance of audits of financial business records, provider and subscriber medical data, claims, systems' reports, medical records, analysis of contract documents,

provider/subscriber

claims history, benefits, external data banks and other documents to determine the possible existence of fraud and/or abuse.
Provide support for offsite

audits/investigations

and interviews when requested. Research

provider/subscriber

claims activity, operations manuals, data systems, medical policies, job duties and group benefit contracts to identify control deficiencies and non-compliance.

Investigator will develop documentation to substantiate finding including formal reports, spreadsheets, graphs, audit logs, use of anti-fraud software and appropriately sourced reference materials.

Must ensure audits and investigations are timely, effective and result in an overall achievement of unit goals.

Investigator researches and analyzes claims data using company anti-fraud software, Excel, and other tools to proactively identify new potential cases Investigator will develop documentation that supports conclusions, recommendations, and substantiates findings including formal correspondence, audit reports, spreadsheets, graphs, audit logs, anti-fraud software analysis, and appropriately sourced reference materials.

Investigator ensures timely maintenance and organization of case file documentation with a high level of detail and accuracy that clearly and concisely outlines investigative steps, case synopses, and findings and to preserve as potentially discoverable material
Thanks & Regards,

• LAXMAN

KMM Technologies, Inc.
CMMI Level 2 | ISO 9001 | ISO 20000 | ISO 27000 Certified
WOSB, SBA 8(A), MDOT MBE & NMSDC MBE


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