Medical Investigator I / II

Join to apply for the Medical Investigator I / II role at Univera Healthcare

Job Description : Under the guidance of the SIU Management, this position is responsible for the accurate and thorough clinical investigation of potential fraud, waste and abuse (FWA) for all lines of business.

The scope of accountability includes investigating and remediating allegations of FWA while adhering to compliance and regulatory requirements. Primary activities include substantiating referrals, case planning and research, conducting onsite or desk audits, clinical reviews of medical records to ensure correct billing of services and appropriateness of care, interviewing potential witnesses, developing corrective action plans, developing correspondence to impacted parties, managing disputes, and collaborating with law enforcement and regulatory agencies.

Essential Accountabilities

Level I

• Functions as a clinical reviewer of medical records, researching and investigating complex medical cases.
• Thoroughly researches allegations or issues and develops sources of information to create a plan of action, accumulates sufficient detailed evidence including statements, documents, records and exhibits.
• Prepares comprehensive summary reports and assures accuracy of information provided to providers, regulators, law enforcement, Legal, Compliance and outside counsel.
• Analyzes proactive detection reports and claims data to identify red flags / aberrant billing patterns.
• Manages cases as assigned, prioritizing case load as appropriate.
• Acts as primary point of contact with law enforcement for assigned cases and may be required to prepare files and testify in court, as needed, in matters regarding litigation related to their reviews.
• Prepares recommendations on preventive / corrective measures for the deterrent of future fraud.
• Supports other SIU investigators and analysts with their cases by providing clinical information / expertise and as necessary, performs clinical reviews of medical records.
• Consults with external practitioners, medical professional groups and agencies, professional medical associations, the BlueCross BlueShield Association, the Food and Drug Administration (FDA), and Centers for Medicare and Medicaid Services (CMS).
• Maintains accurate and up-to-date knowledge of all Government Programs regulations (Medicaid, Medicare, Federal Employee Program, New York State Department of Financial Services, etc.).
• Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies' mission and values, adhering to the Corporate Code of Conduct, and leading to the Lifetime Way values and beliefs.
• Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures.
• Regular and reliable attendance is expected and required.
• Performs other functions as assigned by management.

Level II (in addition to Level I Accountabilities)

Level III (in addition to Level II Accountabilities)

Minimum Qualifications

Physical Requirements

Equal Opportunity Employer

In support of the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position.

Compensation Range(s)

Level I (E2) : Minimum : $60,410 - Maximum : $96,081

Level II (E4) : Minimum : $65,346 - Maximum : $117,622

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.

J-18808-Ljbffr