Clinical Investigator

Amerihealth Caritas•,

3d•Remote

About The Position

The Clinical Investigator is responsible for performing comprehensive clinical investigations and reporting for the purposes of identifying, investigating, and correcting fraudulent and/or abusive billing and coding practices. The Clinical Investigator reviews and analyzes medical records and other documentation to determine the accuracy and appropriateness of billing for documented services, including: assessing the appropriateness of services with respect to the Member's behavioral health condition; evaluating the accuracy of coding compared to medical records; and documenting rationale for review decisions. This position will manage a caseload from receipt of referral through case resolution resulting in preparation of all documentation for further investigation.

Requirements

Master's Degree required in psychology, social work, or related field
Experience in providing direct service or involvement in Behavioral Health
Experience with BH-MCOs preferred
Knowledge of and experience working in various Behavioral Health levels of care
Practical experience in the use of computerized databases
Familiarity with claims payment, coding and reimbursement methodologies
Ability to make decisions with supporting documentation independently, combined with team and leadership interactions
Ability to work collaboratively with the assigned line of business, County Oversight entities, providers, BPI, OMHSAS and others
Excellent verbal and written skills with strong research skills
Experience using Microsoft Excel and Data Mining different data sets
Must have access to a reliable high-speed internet connection to support daily job responsibilities. A minimum bandwidth of 50 Mbps download and 5 Mbps upload is required.

Nice To Haves

Licensure preferred - LSW, LCSW, or LPC
Accredited Health Care Fraud Examiner (AHFI) and/or Certified Insurance Fraud Investigator (CIFI) preferred or willing to obtain within one year of employment

Responsibilities

Provide clinical investigation analysis and reporting with specialized analytical skills and knowledge using internal and external data systems. Within areas of job responsibilities, identify systemic issues of fraud waste and/or abuse for the AmeriHealth Caritas Family of Companies
Responsible for coordination with the PerformCare Claims, Finance and other Departments regarding overpayments and case development
Responsible for producing and developing case reporting as deliverables to designated LOB Oversights and others as deemed appropriate; and also updates case tracking system with all case actions and follow up. Responsible for making referrals to BPI, the OAG and others if deemed appropriate based on the development of a case
Assist with coordination of recovery of overpayments related to fraudulent and/or abusive billing and coding practices; and education related to coding, medical record documentation requirements, and government- funded healthcare compliance and fraud, waste and abuse to Health Plan staff, vendors and contracted providers/facilities
Participate in clinical Fraud, Waste and Abuse measurement projects, helping to develop enhanced clinical analysis data systems, and serving as a resource for developing Fraud, Waste and Abuse investigative results and solutions
Interfaces with providers and may be responsible for conducting on-site audits