Healthcare Fraud Investigator II - Medicaid/MCO
Orchard Talent Management
Seattle, WA
JOB DETAILS
JOB TYPE
Full-time, Employee
SKILLS
Advertising Scheduling, Auditing, Claims Processing, Content Development, Content Management Systems (CMS), Data Analysis, Department of Health and Human Services, Developmental Disabilities, Electronic Medical Records, Federal Bureau of Investigation (FBI), Foundation Grants, Fraud Investigation, Health Plan, Healthcare, Human Health, Law Enforcement, Managed Care, Medicaid, Medicare, Meeting Minutes, Nonprofit, Organizational Development/Management, Problem Solving Skills, Quality Assurance, Quality Management, Quality Monitoring, Reconciliation, Resource Management, Return on Investment (ROI), Talent Management, Technical Delivery, Utilization Management
ADDITIONAL COMPENSATION
see description
LOCATION
Seattle, WA
POSTED
18 days ago
Healthcare Fraud Investigator II - Medicaid/MCO
Remote in one of these states: CA, AZ, OR, WA, UT, MT, ID, NV
@Orchard LLC is retained by a not-for-profit corporation that partners with public and private sectors to create high quality, safe, and efficient delivery of health care and human services programs. We have multiple lines of business including population health, utilization review, managed care organization quality review, and quality assurance for programs serving individuals with developmental disabilities. Our Client is also a national leader in fighting fraud, waste and abuse for large organizations across the country. In addition, our Foundation provides grant opportunities to those with programs for under-served communities.
Monitors the processing and reconciliation of incoming electronic medical records, importing of prepay claims and records, and generating other operation reports related to process of prepay claims. Supports research of prepay and post-pay record questions as well as research and return of misdirected documents.
Essential Duties and Responsibilities:
- Monitors QMS procedures, work instructions, and job aids. Provides first level review for changes.
- Supports problem-solving solutions for system issues.
- Provides expertise for implementing, deactivation, monitoring, quality assurance, and reporting of prepay edits.
- Facilitates meetings and coordinates presentations.
- Tracks and analyzes data and reports for prepay committee edit effectiveness; creates presentations.
- Assigns incoming and outgoing external contractor communications; monitors completion of requests.
- Researches prepay and post-pay record questions. Reports quality assurance for appeal requests, recalculations, and redeterminations.
- Schedules coordination of ad hoc calls with external contractors or law enforcement; takes minutes.
- Reviews and comments on Medicare JOAs.
- Creates templates and content for the external contractor annual fraud and abuse training.
Education and /or Skills and Experience Required:
- Minimum Bachelor's Degree
Preferred Skills/Experience:
- Certified Fraud Examiner or Accredited Healthcare Anti-Fraud Investigator
- Prior successful experience with CMS and OIG/FBI or similar agencies
- Medicaid investigation experience strongly preferred
If you match the requirements for this opportunity and believe you have the experience and talent to succeed in the role, we need to hear from you!
Established in 2010, @Orchard LLC, also known as, Talent Orchard has an exceptional reputation, providing staffing solutions to time-sensitive, talent scarcity issues to deliver better talent management ROI. Our specialty lies in the critical area of program talent acquisition and resource management, not in one narrow skillset, but across many areas of technical and functional delivery. To learn more about our other exciting opportunities, visit our Jobs Page at www.atOrchard.com.
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About the Company
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