330 West 42nd Street
The 1199SEIU Benefit & Pension Funds provide comprehensive health, pension, and quality of life benefits to unionized workers represented by 1199SEIU United Healthcare Workers East. We are among the largest labor-management funds in the nation, covering 400,000 members and their families.
If you’re ready for the brightest career future, join us in this excellent opportunity to showcase your talents. We are currently seeking for an experienced Principal Investigator for our Fraud & Abuse department.
- Perform accurate and reliable medical record review audits to verify if services are supported by clinically appropriate documentation; determine if services were appropriately administered; and/or validate coding and billing accuracy. Utilizes extensive knowledge of medical terminology, ICD-9-CM, HCPC Level II and CPT coding along with analysis
- Recognizes and adheres to national and local coding and billing guidelines in order to maintain coding accuracy and excellence
- Produces reliable, accurate and timely written reports for internal and/external review detailing audit findings, based on industry standard(s) and/or internal policy and procedure
- Provides guidance and assistance to other investigators in conducting medical record review audits
- Researches new healthcare related questions as necessary to aid in investigations
- Recommends possible interventions for loss control and risk avoidance based on the outcome of the investigation
- Coordinates with various internal customers to gather documentation pertinent to investigations.
- Incorporates leadership and communication skills to work with physicians, other health professionals, attorneys as well as external regulatory agencies and law enforcement personal
- Conducts settlement negotiations with providers and/or attorneys on cases in which the Fund has sent a demand for overpayment
- Communicate effectively and collaboratively with internal staff, leadership and external customers in a professional manner
- Perform special projects and assignments as directed by management
- Maintain the confidentiality required of the organization and the department
- Follow all Health Insurance Portability and Accountability Act (HIPAA) and Personal Health Information (PHI) requirements and regulations
- Must meet performance standards including attendance and punctuality
- Bachelor’s Degree in Nursing, Business, Criminal Justice or related field required
- Certified Professional Coder (CPC) and/or Accredited Healthcare Fraud Investigator (AHFI) a plus
- Minimum of four (4) years experience with medical coding and medical record review audits performed with little to no supervision required
- Minimum of four (4) years experience in healthcare fraud required
- Proven track record in investigations and/or the identification and pursuit of the recovery of overpayments
- Excellent report writing skills
- Ability to meet defined performance and production goals
- Knowledge of physician’s coding and billing best practices and methodologies as per industry standards
- Knowledge of claims business operations including claims processing, and reimbursement procedures, solid understanding of fraud detection and prevention practices
- Intermediate Microsoft Office/Suite applications (Excel, Word, PowerPoint, Outlook, etc.) required
- Excellent interpersonal and communication skills – oral, written and listening
medical, dental, no copay, prescription, tuition reimbursement, 401k
Minimum Education Required
How To Apply
We offer a competitive salary, an excellent fully employer-paid comprehensive benefits package and talented professional colleagues. For consideration and to apply, please visit us at http://chm.tbe.taleo.net/chm03/ats/careers/requisition.jsp?org=NBF1199&cws=1&rid=7169. Please mention you saw this ad in Idealist. We are an Equal Opportunity Employer.