Fraud Examiner
HealthFirst
Summary
The Fraud Examiner will be responsible for effectively providing support to all SIU investigators by carrying out preliminary investigative tasks, conducting data analysis and supporting SIU responses to audits and external entities.
Job description
- Synthesize, analyze and process healthcare claims data and financial information in Excel, creation of tables/pivot tables for internal review and reporting
- Support HF SIU FWA team by maintaining an Agency Referral Log of all incoming agency requests for information (RFI)
- Obtain necessary information in response to RFIs to present to legal department for approval
- Monitor Restricted Recipient Program (RRP) by notifying appropriate departments of incoming informational packets
- Mailing of information regarding RRP to members
- Coordinate member and provider packets for members restricted by Member Review and Restriction Committee
- Monitors internal mailboxes for incoming investigative inquiries
- Assist investigators with interviews, review of information and determination for further investigative steps; assist with Marketing Incidents Committee Meeting by attending meetings and managing notes and minutes, update Marketing Log with MIC decisions and directives
- Assist SIU colleagues with Fraud, Waste and Abuse issues and problem solve
- Additional duties as assigned, including but not limited to minor administrative tasks in support of the department
Minimum Qualifications
- AA/AS degree from an accredited institution
- Intermediate Word and Outlook skills
- Intermediate/Advanced Excel skills including pivot tables and basic formulas
- Data analysis experience
- Prior experience in either insurance claims investigation/audit or other professional investigations
- Critical thinking, analytical skills and teamwork experience
- Good oral and written communication skills including an ability to summarize data analysis and contribute to investigative reports
Preferred Qualifications
- Bachelor's Degree from an accredited institution
- Experience with Tableau and/or SAS
- Knowledge of Medicare and Medicaid and/or healthcare claims data
- Knowledge of medical claims processing and investigations and the ability to read medical records
- Knowledgeable about applicable fraud statutes, regulations, CMS guidelines, Federal and State insurance reporting requirements
- Professional conduct in dealing with persons internal and external to the organization
- Spanish or other language proficiency
Requirements
- AA/AS degree from an accredited institution
- Intermediate Word and Outlook skills
- Intermediate/Advanced Excel skills including pivot tables and basic formulas
- Data analysis experience
- Prior experience in either insurance claims investigation/audit or other professional investigations
- Critical thinking, analytical skills and teamwork experience
- Good oral and written communication skills including an ability to summarize data analysis and contribute to investigative reports
Benefits
- Medical, Dental & Vision
- Incentive Programs
- Recognition Programs
- Life Insurance
- 401(k) Contributions
Company overview
HealthFirst is a medical equipment manufacturing company specializing in the development and production of healthcare devices and diagnostic equipment. As a medical device manufacturer, the company focuses on creating innovative solutions that enhance patient care and improve clinical outcomes. HealthFirst operates in the competitive medical technology sector, where it likely develops products ranging from diagnostic instruments to therapeutic devices used in various healthcare settings. The company's commitment to quality and regulatory compliance positions it as a reliable provider of medical equipment to hospitals, clinics, and healthcare facilities. With expertise in medical device engineering and manufacturing, HealthFirst contributes to advancing healthcare technology while maintaining rigorous standards for safety and efficacy. The company's products are designed to meet the evolving needs of healthcare professionals and patients, supporting improved diagnosis, treatment, and monitoring of medical conditions across different therapeutic areas.