Fraud and Abuse Investigator
Location: Lincoln, Nebraska
Description: Magellan Health Services is hiring Fraud and Abuse Investigator right now, this occupation will be depute in Nebraska. More complete informations about this occupation opportunity please read the description below. (
Job Number:
15191
)
Job Summary
This position is responsible for conducting objective, fair, thorough, unbiased and timely inves! tigations into allegations of healthcare fraud, waste or abuse committed against company by members, providers or other entities. The position requires ingenuity and creativity to obtain case information not readily available, along with the ability to work independently with minimum supervision, and good organizational skills needed to manage a high volume of assigned cases as well as the regular exercise of independent judgment and initiative to investigate allegations. The investigator must have the analytical ability necessary to review, interpret and evaluate relevant information essential in resolving sensitive and complex investigations.
Essential Functions
Manage referrals and prioritize investigations. Conduct investigations with a focus on thoroughness, quality, and attention to detail, timeliness and cost control to detect fraud, waste or abuse on claims against the company. Assess the scope and determine the methodology needed to carry out an e! fficient investigation. Prepare comprehensive investigative re! ports and analysis, documenting all evidence obtained in the investigation in order to substantiate meritorious claims, to deny unjustified claims, to recover inappropriate payments or to recommend action against responsible parties. Provide investigative expertise to limit exposure and protect company assets. Apply knowledge about applicable local, state and federal fraud statutes to ensure duties and assignments are carried out within the requirements of applicable law and local office expectations.
Coordinate with legal, finance, networks, claims, compliance and other internal departments to respond to subpoenas, affidavits and other requests. Provide customer service and relationship/team building by maintaining contact during the course of investigations with various internal departments, claimants, and policyholders, counterparts in other firms, and government /regulatory agencies.
Establish and maintain liaison with public officials, law enforcement! officers and others to obtain and provide assistance in conducting investigations. Develop network of resources within the community (e.g., local fraud bureaus, district attorneys offices, law enforcement agencies, insurance associations, professional associations, and community groups).
Assist with the development and training of company personnel in the detection of external and or internal fraud and associated regulatory requirements.
Minimum Requirements
Education:
BA/BS
Experience:
5-8 years
Industry:
Five to eight years fraud investigations, claims processing, auditing or provider networks at expert level
An equivalent combination of experience and education is acceptable.
Other
A thorough knowledge of the various types of insurance fraud and the strategies and techniques used in their investigation and of federal and state regulations as it relates to those techn! iques are required. Qualified candidates must have knowledge of various! government and professional agencies, bureaus and boards which provide personal identification and licensing information. The position may require knowledge of medical terminology and practices. The candidate must have excellent written and verbal communication skills used for interviewing and corresponding with claimants, attorneys, doctors, law enforcement, etc. The candidate must be able to work independently with minimum supervision and possess good organizational skills. A high degree of integrity and confidentiality is required for handling information that is considered personal and confidential.
Computer Skills:
Database management, spreadsheet and word processing skills
Lifting:
25lbs.
Primary Location
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NE-Lincoln NE-1221 N Street
Work Locations
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1221 N Street (NE01)
1221 N Street
Suite 700
Lincoln
68508
Magellan Health Servi! ces is a leading specialty health care management organization with expertise in managing behavioral health, radiology and specialty pharmaceuticals, as well as public sector pharmacy benefits programs. We deliver innovative solutions to make a positive impact on the cost and quality of health care, keeping the best interests of the people we serve at the center of our decision-making. The breadth of our offerings, depth of expertise, clinical excellence and smart, talented employees is what makes us unique.
Magellan is the employer of choice for hard working people interested in making a difference in the health care industry and in the communities where we work and live. Our strong culture of caring is the common thread in both our business strategy and our work environment where we value professional growth and development, total health and wellness, rewards and recognition and employee unity. Magellan is a place where you can thrive.
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If you wer! e eligible to this occupation, please give us your resume, with salary ! requirements and a resume to Magellan Health Services.
Interested on this occupation, just click on the Apply button, you will be redirected to the official website
This occupation starts available on: Sun, 04 Aug 2013 10:33:22 GMT
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