Job Description
SUMMARY: The Payment Integrity / Special Investigation Unit (PI/SIU) Specialist is responsible for managing the audit functions across all lines of business as well as all fraud, waste and abuse (FWA) activities for HNE. The PI/SIU Specialist is responsible for developing, executing and overseeing a comprehensive risk based audit & FWA plan with the objectives of detecting, investigating, preventing and resolving (through prosecution or otherwise if necessary) cases of health care fraud, waste and abuse; auditing daily operational activities, safeguards, processes and procedures to validate they are functioning properly. The role will be responsible for implementing policies that meet or exceed government requirements; to minimize financial, legal and customer service risk exposures. This individual must be able to effectively present information and establish clear understanding and buy-in.
ESSENTIAL FUNCTIONS:
Audit 50%
- Participate in configuration design review sessions, and evaluate level of complexity and identify potential exposure in contract/configuration set-up.
- Audit complex hospital and provider contracts compared to claim payment system in order to confirm appropriate configuration including but not limited to; audit for correct claim coding, validation of billed services, consistent application of payment rules
- Identify opportunities for the establishment of audit activities in support of HNE's critical business functions and coordinate audit activities with other departments
- Provide feedback and process improvement recommendations to appropriate health plan operation departments and participate in workgroups/committee meetings and process improvement solutions as required.
- Coordinate corrections with claims and membership areas.
- Communicate information, observations and findings to other departments in order to prevent inappropriate payment of claims.
- Communicate and coordinate reviews with physician office staff and distribute correspondence related to the review. Assess review data to determine areas of improvement for follow up physician training and communication.
- Maintain continuous accurate and complete documentation for department specific, ongoing, and situational audits and recommend revisions/improvements to audit functions
- Perform audits on-site, electronically or in the field.
Payment Integrity 20%
- Research, interpret and provide clear direction to the stakeholder departments on new and changing code requirements, covered and non-covered determinations and payment schedules and provide fact-based recommendations.
- Provide leadership and collaborate on internal and external audits.
- Develop financial models and tools, including cost-benefit analysis, claims trend analysis.
SIU / FWA - Detection and Prevention 30%
- Develop and perform a comprehensive FWA monitoring program for government programs (Medicare and Medicaid)
- Investigates cases of known, reported or suspected fraud, waste and abuse
- Gather, analyze, evaluate facts and evidence and draw sound conclusions
- Determine whether fraud (intent) or abuse (without defined intent) was the outcome utilizing sound conclusions
- Assist with identifying opportunities for improvement and correction actions designed to strengthen internal controls, correct underlying problems that may result in fraud, waste or abuse and prevent further misconduct
- Assist with oversight of auditing services from outside vendors and HNE business partners.
- Manage and investigate incidents/leads as assigned related to areas of regulatory, compliance, fraud, waste and abuse and violation of policy and procedure. Report issues to Compliance Manager and Director of Payment Integrity/SIU
- Develop reporting for FWA and compliance activities
Related Responsibilities
- Stays abreast of current coding issues and changes, reviews medical coding trends and identifies potential training needs.
- Ensure compliance with regulatory requirements and standards. Understand regulatory environment and ensure contractual compliance with federal and state requirements (Medicare, Medicaid).
MINIMUM REQUIREMENTS:
Bachelor's degree in Business, Healthcare Administration or related field with more than 3 years claims auditing experience; or more than 3 years experience in Fraud, Waste &
Abuse preferably in an HMO or MCO; or an equivalent combination of education and experience.
- Experience in Medicare compliance
- CPC and or CPC-H certification preferred
- CPMA certification preferred
- Understanding of Commercial insurance business practices and government health insurance products (Medicare& Medicaid).
- Proficiency with healthcare coding (CPT/HCPCS, ICD-9 and ICD-10 & Revenue Codes)
- Working knowledge and experience in cross-functional business segments and their integrated influences and relationships
- Highly effective research, writing, and communication skills
- Skilled with Microsoft Office Suite (Access, Word, Excel, PowerPoint)
- Good problem solving skills
- Excellent organizational skill
- Strong attention to detail
- Excellent critical thinking, and analysis skills
- Ability to understand and interpret government health insurance laws and regulations
- Ability to present an unpopular opinion
- Ability to work well independently or with others
- Ability to work well with both internal and external customers
WORKING CONDITIONS: Works in a standard office-based environment