Experienced Associate, Healthcare Forensics - Raleigh, NC, United States
3 days ago
Job description
DescriptionJob Summary:
The Experienced Associate, Healthcare Forensics role is a highly analytical and detail-oriented individual responsible for identifying, analyzing, and resolving payment inaccuracies across healthcare claims as it relates to reimbursement disputes, fraud, waste, and abuse investigation, regulatory compliance, and litigation. The ideal candidate will bring a strong understanding of healthcare reimbursement methodologies, claims data, and regulatory frameworks. The Experienced Associate, Healthcare Forensics demonstrates an investigative mindset with problem solving skills and the ability to think critically about data to deliver high-quality work product for clients.
Job Duties:
- Provides investigation and analysis to a variety of clients, including outside counsel, regulators, and companies involved in litigation, investigation, dispute, regulatory, and compliance matters
- Contributes to forensic engagements related to medical coding and billing, revenue cycle, payment integrity, the False Claims Act, the Stark Law, the Anti-Kickback Statute, and other matters
- Analyzes healthcare claims data to identify improper payments, billing errors, and potential fraud, waste, or abuse
- Develops and implements strategies to improve payment accuracy and mitigate overpayments
- Collaborates with cross-functional teams to validate findings and recommend corrective actions
- Interprets payer policies, provider contracts, and regulatory guidelines to assess claim appropriateness
- Prepares and present detailed reports and recommendations to clients and internal stakeholders
- Supports the design and enhancement of payment integrity tools, algorithms, and audit methodologies
- Stays current on industry trends, CMS regulations, and emerging payment models.
- Develops working relationships with internal and external stakeholders and communicates effectively
- Assists with the preparation of high-quality deliverables to ensure client satisfaction
- Acts with professionalism and integrity when working with confidential and sensitive information
- Maintains a proactive and logical approach to information gathering, combining complex ideas and clear and effective information presentation
- Identifies and researches new trends, tools, and understands the data analytics marketplace while working on client engagements
- Assists with developing documents, procedures, and solutions on non-billable practice development initiatives
- Other duties as required
Supervisory Responsibilities:
- N/A
Qualifications, Knowledge, Skills, and Abilities:
Education:
- High School Diploma or equivalent, required
- Bachelor's degree in Healthcare Administration, Public Health, or Business, preferred
Experience:
- Three (3) years of experience in healthcare consulting, revenue cycle, claims auditing, or payment integrity, required
- Experience with healthcare reimbursement (Medicare, Medicaid, Commercial), coding (ICD-10, CPT, HCPCS), and claims processing, preferred
- Experience in the following areas, preferred:
- Forensic Analytics
- Compliance Analytics
- Artificial Intelligence
- Fraud Analytics
License/Certifications:
- Nationally recognized coding credential (e.g. CPC, CCS, RHIA, RHIA), preferred
- Certified in Healthcare Compliance (CHC), preferred
Software:
- Proficiency in data analysis tools (e.g., Excel, SQL, SAS, Tableau), preferred
- Prior experience with Electronic Health Record software (e.g., EPIC, Cerner, Athena, etc.), preferred
- Coding/DRG software, preferred
Other Knowledge, Skills & Abilities:
- Ability to work with a high degree of professionalism and autonomy
- Excellent verbal and written communication skills
- Ability to communicate complex information in a clear and concise manner
- Excellent communication, problem-solving, and project management skills
- Ability to work independently and manage multiple priorities in a fast-paced environment
- Solid organizational skills, especially the ability to meet project deadlines with a focus on details
- Ability to successfully multi-task while working independently or within a group environment
- Ability to work in a deadline-driven environment, and handle multiple projects simultaneously
- Ability to interact effectively with people at all organizational levels of the Firm
- Ability to work collaboratively with others with accountability for work product
Keywords: Forensic, Healthcare Coding, Payment Integrity, Revenue Integrity, Revenue Cycle Management, Consulting, Disputes, Litigation, Investigation, Fraud, Waste, Abuse, Coding Auditor, Charge Capture, Healthcare Compliance
Individual salaries that are offered to a candidate are determined after consideration of numerous factors including but not limited to the candidate's qualifications, experience, skills, and geography.
National Range: $65,000 - $85,000
Maryland Range: $65,000 - $85,000
NYC/Long Island/Westchester Range: $65,000 - $85,000
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