Investigation Analyst Senior

Spectrum Health is committed to hiring and investing in some of the brightest and most talented people in the world, no matter their gender, race, religion or background. Our top-notch teams are comprised of collaborators, leaders and innovators that continue to build on one shared mission statement - to improve health, instill humanity and inspire hope.

Grand Rapids, MI, USA

Spectrum Health

We are committed to offering a unique solution tailored for you. We focus on your needs and on healing the whole you. We listen to our patients. We consider their physical and emotional needs, extending essential financial education and assistance when necessary.

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Full Time

Competitive Compensation Package

Overview: Responsible for complex fraud and abuse investigations and data analysis to identify trends, detect fraud and abuse, limit exposure and protect company assets. Analyzes and monitors highly technical information into actionable investigative strategies. Responsible for preparing documents for regulatory site visits. Acts as a liaison with local/state/federal law enforcement personnel, industry advocates in other companies. Identifies new audit opportunities. Prepares and presents fraud and abuse education to internal departments. Serves as a mentor/trainer to other team members.
Responsibilities: <ul> <li>Responsible for high level, complex investigations to pursue health care fraud and abuse to recover lost funds and ensure corrective action is taken as applicable. Investigations include collecting, researching data in order to detect fraudulent or abusive practices by utilizing system tools, interviews, medical records audits, data mining, perform compliance audits of medical claims, fee screens and other payment mechanism to ensure accurate payment. Routinely handles cases that are sensitive or high profile, involving multi-disciplinary provider groups or cases involving multiple perpetrators or intricate healthcare fraud schemes.</li> <li>Investigate fraud and abuse tips received through the compliance hotline, internal referral or identify through data analytics. Support information requests my government agencies, law enforcement, external auditors, etc. Conduct telephone and in person interviews which may include members, providers, employer group agents etc. to determine validity of allegations of fraud waste and abuse. May include conversations with law enforcement and regulatory agencies.</li> <li>Prepare financial analyses and reports to document finding and maintain up to date case files and case tracking system. Case files to include documentation to substantiate investigative process, findings, final report. In addition, notifications of finding letter for dissemination to provider or affected entity, notification letters to regulatory agencies if applicable. Ability to negotiate settlement offers and present to management and legal for approval.</li> <li>Participates in building and enhancing organizational capabilities by developing and participating in the delivery of fraud awareness and mentoring lower level SIU staff. Keeps current on laws, regulations, trends and emerging issues. Demonstrates high level of knowledge and expertise during interactions and acts confidently during all aspects of the investigation including coordinating activities with law enforcement and testimony if needed. Responsible for understanding plan documents, provider and agent agreements, products offered, State and Federal laws related to fraud, waste or abuse, Medicare and Medicaid regulations, etc.</li> </ul>
Requirements: <div> <ul> <li>Required Bachelor's Degree or equivalent preferably in a health, business or related degree</li> </ul> </div> <div> <ul> <li>5 years of relevant experience experience working in health care including two years of relevant experience working in health care fraud Required</li> <li>7 years of relevant experience progressively more responsible experience working in fraud and abuse investigations or analytical role in a health related business such as&nbsp;hospital/physician/pharmacy/ancillary&nbsp;provider, audit, billing, compliance or health insurance Preferred</li> </ul> </div> <div> <ul> <li>CRT-Registered Health Information Technician (RHIT) - AAPC American Academy of Professional Coders Upon Hire required Or</li> <li>CRT-Registered Health Information Administrator (RHIA) - AHIMA American Health Information Management Association Upon Hire required Or</li> <li>CRT-Professional Coder - AAPC American Academy of Professional Coders Upon Hire required Or</li> <li>CRT-Professional Coder, Certified - Payer (CPC-P) - UNKNOWN Unknown Upon Hire required Or</li> <li>CRT-Outpatient Coder, Certified (COC) - UNKNOWN Unknown Upon Hire required Or</li> <li>CRT-Coding Specialist (CCS) - AHIMA American Health Information Management Association Upon Hire required Or</li> <li>CRT-Coding Specialist, Certified-Physician Based (CCS-P) - AHIMA American Health Information Management Association Upon Hire required</li> <li>CRT-Fraud Examiner - UNKNOWN Unknown Upon Hire preferred Or</li> <li>CRT-Accredited Health Care Fraud Investigator (AHFI) - NHCAA National Health Care Anti-Fraud Association Upon Hire preferred</li> </ul> </div>