Special Investigator - Albany, United States - CAPITAL DISTRICT PHYSICIANS HEALTH PLAN INC

CAPITAL DISTRICT PHYSICIANS HEALTH PLAN INC

Verified Company

Albany, United States

3 weeks ago

Posted by:

Mark Lane

beBee recruiter

Description

Grounded by a compelling mission, core values, and compassion for people, CDPHP and its family of companies offer a strong foundation for a rewarding career.

Established in 1984, CDPHP is a physician-founded, member-focused, and community-based not-for-profit health plan that offers high-quality affordable health insurance to members throughout New York.

The company values people, quality, innovation, and community, and its corporate culture supports those values wholeheartedly. CDPHP is committed to fostering a culture of belonging and takes a wholistic approach to diversity, equity, and inclusion.

At CDPHP, the employees have a voice and are encouraged to make an impact at both the company and community levels through engagement and volunteer opportunities.

CDPHP invests in employees who share these values and invites you to be a part of that experience.

The SIU Special Investigator will be responsible for investigating complex insurance cases to detect internal and external fraud and abuse.

The Special Investigator will research and document cases utilizing resources available to identify suspicious billing patterns and trends.

The Investigator will prepare case reports and documents as well as conduct interviews of providers, members, and person/persons with knowledge of the matter under investigation.

They will assist in performing audits of providers' claim submissions to assure that services rendered and billed correspond with members' medical records.

They are responsible for recognizing violations of CDPHP provider and/or member' contracts/agreements, policies and procedures, and State and Federal laws pertaining to the health care industry.

The Special Investigator will coordinate referrals of suspicious instances of fraud and abuse to state and federal agencies as well as assist with negotiating favorable financial settlements on behalf of CDPHP or in preparation of civil suit.

The Special Investigator will take an active role in the training of CDPHP employees, providers, and members in the identification and remediation of fraud, waste, and abuse.

QUALIFICATIONS:

Degree in Criminal Justice or related field preferred.
Bachelor's degree or four (4) years of equivalent experience required.
Designation as an Accredited Health Care Fraud Investigator preferred.
Incumbent must meet one of the minimum qualifications outlined below, in line with New York State requirements:
Associate's or Bachelor's degree in criminal justice or related field, or
Minimum five (5) years of insurance claims investigation experience or professional investigation experience with law enforcement agencies or
Minimum seven (7) years of professional investigation experience involving economic or insurance related matters.
Experience with CPT and ICD9 coding used in health care benefits and claims processing required.
Experience working with complex contracts with healthcare systems, large medical groups, hospitals, ancillary providers, individual practitioners, and members for Commercial, Medicare, and Medicaid lines of business required.
Experience with payment methodologies required.
Experience working with law enforcement, responding to subpoenas and/or testifying in Federal and State court proceedings preferred.
Experience with Microsoft Office, including Word, Excel, Outlook, and PowerPoint is required, experience with Access preferred.
Demonstrated ability to identify and determine fraudulent activity and compile necessary documentation in a clear concise manner.
Demonstrated ability to analyze claims to determine correct processing.
Demonstrated ability to present complex information in a digestible manner to both internal and external parties, including law enforcement and/or in court proceedings.
Demonstrated knowledge of broker responsibilities and requirements.
Demonstrated knowledge of payment methodologies.
Demonstrated analytical, decision making, and problemsolving skills.
Demonstrated ability to work collaboratively with multiple partners to positively affect outcomes at the team, organization, and member level.
Must be detailoriented with strong organizational skills, including the ability to coordinate workflow.
Demonstrated ability to provide excellent customer service and develop relationships both internally and externally.
Demonstrated ability to work with and maintain confidential information.

CDPHP and its family of companies include subsidiaries Strategic Solutions Management Consultants (SSMC), Practice Support Services (PSS), and ConnectRx Services, LLC.