Fraud & Investigations, Professional, SIU Investigative Analyst

Company: MVP Health Care, Inc.
Location: Schenectady
Posted on: May 14, 2022

Job Description:

Fraud & Investigations, Professional, SIU Investigative Analyst Headquarters Office, 625 State Street, Schenectady, New York, United States of America

• Rochester Office, 220 Alexander Street, Rochester, New York, United States of America
• Tarrytown Office, 303 South Broadway, Tarrytown, New York, United States of America
• Virtual Req #1084 Wednesday, March 23, 2022 Over 35 years strong and fueled by 1,700 smart, passionate employees across New York state and Vermont, MVP is full of opportunities to grow. We are a nationally recognized, award-winning leader for a reason. The beating heart of our company is a wide range of employees from a diverse set of backgrounds-tech people, numbers people, even people people-working together to make health insurance better. If you are ready to join a thriving, mission-driven company where you can create your own opportunities and make a positive difference-it's time to make a healthy career move to MVP! Under the direction of SIU Management, the Investigative Analyst, will support SIU Investigators in the course of fraud, waste, and abuse investigations. The analyst will conduct prepayment and post payment medical record reviews, consolidate overpayments identified, submit detailed findings to SIU Investigators, and support investigation activities as needed. Essential Job Functions:

• Ability to utilize various data tools to help identify overpayment when comparing medical records to claims data. Must have working knowledge of MS Office (Word, Excel and Outlook), Macess, Facets, CareRadius, CMS Guidelines, and professional association guidelines as they related to various types of specialty medical services.
• Possess knowledge of CPT-4, ICD-9-CM, ICD-10-CM, HCPCS and CPT Assistant coding guidelines as they relate to claim data.
• Conduct clinical reviews of various forms of medical documentation and records obtained from providers and facilities including but not limited to medical charts, facility records, and patient account records.
• Organize and conduct highly complex review findings. Document findings and recommendations throughout the record review process in a timely and efficient manner according to corporate and departmental SIU policies and procedures.
• During the course of the record review, cooperate and leverage subject matter expertise from
• Assist with investigations conducted by government agencies, law enforcement, and other insurance company SIU staff.
• Testify in criminal and civil legal case proceedings as necessary and assist outside legal counsel especially concerning issues needing coding expertise decision making.
• Participate in annual Corporate FWA training and training of new SIU personnel.
• Keep abreast of Federal and State anti-fraud investigation and reporting requirements including HIPAA, CMS, Medicare, Medicaid, and any corporate compliance initiatives or policies.
• Minimal travel may be required pertaining to investigations and audits. Job Qualifications:
  • Certified Professional Coder (CPC) required.
  • Experience in medical record review as it relates to proper coding base on CPT, HCPCS, ICD-9, ICD-10 guidelines required.
  • Maintain coding credentials through continuing
  • Superior judgment skills, verbal and written communication, documentation, and presentation skills.
  • Extremely detail-oriented with excellent organizational and analytical
  • Certified Professional Medical Auditor (CPMA), Certified Inpatient Coder (CIC), Certified Outpatient Coder (COC), Certified Documentation Expert Outpatient (CDEO), Certified Documentation Expert Inpatient (CDEI) are preferred.
  • New York State Licensed Practical Nurse (LPN Strongly Preferred). #LI-RT1 About MVPMVP Health Care is a nationally recognized, not-for-profit health insurer caring for more than 700,000 members in New York and Vermont. Committed to the complete well-being of our members and the communities we serve, MVP makes health insurance more convenient, more supportive, and more personal. We are powered by the ideas and energy of more than 1,700 diverse, employees from all backgrounds, committed to having a positive impact on the health and wellness of everyone we serve. MVP Health Care is an Affirmative Action/ Equal Employment Opportunity (PDF). We recruit, employ, train, compensate, and promote without regard to race, religion, creed, color, national origin, age, gender, sexual orientation, marital status, disability, genetic information, veteran status, or any other basis, e.g., Pay Transparency (PDF), and the EEO is the Law Poster and Supplement protected by applicable federal, state or local law. Any person with a disability needing special accommodations to the application process, please contact Human Resources at hr@mvphealthcare.com Please apply and learn more - including how you may become a proud member of our team.

Keywords: MVP Health Care, Inc., Schenectady , Fraud & Investigations, Professional, SIU Investigative Analyst, Professions , Schenectady, New York