About the Role
Position Summary: The Special Investigations Analyst is responsible for providing compliance and investigative technology support to meet the legal and compliance needs of the organization. This position ensures compliance with all requirements related to Special Investigation Units (SIU), with a focus on detecting fraudulent activity and conducting thorough investigations.
Essential Functions and Responsibilities:
Detect fraudulent activities and collaborate with Legal to determine the most effective investigative methods.
Apply knowledge of healthcare billing and related tools, such as IHCP billing & reimbursement rules, UB Editor, HCPCS Billing Manual, CPT Billing Manual, DRG, and Per Diem billing.
Utilize anti-fraud technologies to enhance investigations.
Understand and analyze CPT, ICD-10, and HCPCS coding to identify potential fraudulent schemes.
Develop and conduct fraud awareness training for Plan team members as needed, promoting an understanding of fraud cases that should be referred for investigation.
Contribute to the development of a Plan-wide approach to fraud detection and prevention, recommending changes to procedures, methods, and systems.
Complete investigations in a timely and effective manner.
Organize assigned investigations, secure necessary information from internal or external sources, and prepare comprehensive reports documenting material evidence.
Understand and interpret state and federal regulations and policies, communicating these to individuals with varying educational and economic backgrounds.
Conduct highly complex and/or confidential investigations at the request of the Legal or Compliance teams.
Perform onsite reviews of provider offices.
Calculate and document overpayments.
Prepare detailed Audit Finding Reports, establishing and presenting credible evidence related to investigative findings.
Maintain accurate internal records related to investigations, including updates to case tracking and monthly reporting applications.
Provide regular updates on investigations, both scheduled and ad-hoc.
Testify in criminal and civil legal proceedings as required.
Stay up-to-date with state and federal anti-fraud requirements.
Perform other duties as assigned to support efficient operations of the department and company.
Requirements
Qualifications:
Required:
Associate degree in business, healthcare, or a related field.
At least three (3) years of experience in progressively responsible positions utilizing analytical skills, with a minimum of two (2) years in compliance or a related function.
Two (2) years of experience with coding, specifically CPT, ICD, HCPCS codes, and standard industry billing procedures for both CMS 1500 and UB04 claims.
One (1) year of experience creating, maintaining, and editing SQL queries.
Preferred:
Bachelor’s degree in business, healthcare, or a related field.
Certification as RHIT, RHIA, CFE, or CPC.
Two (2) years of experience and knowledge of HMO or PPO (e.g., accounting/finance, reinsurance, regulatory compliance, claims processing, membership/eligibility, and actuarial concepts).
Coursework or work experience in statistics.
Knowledge, Skills, and Abilities:
Proficiency with personal computers, advanced database, and spreadsheet applications (e.g., Microsoft Office).
Ability to create and implement monitoring tools for auditing assigned areas.
Experience in developing, maintaining, and managing database applications.
Comprehensive knowledge of Medicare and Medicaid regulations.
Strong research, analytical, and problem-solving skills with the ability to make comprehensive recommendations and/or analyze audit outcomes.
Ability to independently draft concise and accurate reports and prepare presentations on fraud-related matters.
Ability to handle sensitive information with extreme confidentiality.
Flexibility to adapt to changing job priorities and handle multiple projects simultaneously.
Excellent communication, consultancy, facilitation, and conflict resolution skills.
Self-directed, collaborative, and non-confrontational work style.
Commitment to continuous improvement and more efficient work outcomes.
Focus on customer relations and participation in quality improvement projects.
Strong ethical standards and ownership in all endeavors for the benefit of the Plan.
About the Company
RepuCare, a certified Woman-Owned Business (WBE), is a leader in providing innovative workforce solutions. We have partnered with a large managed care organization seeking a Special Investigations Analyst to join their dynamic team. This is a hybrid role that combines in-office and remote work.