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Resp & Qualifications

PURPOSE:

To support the prevention, reduction of and/or recuperation of losses to CareFirst through the clinical review of medical records and claims, resulting in the savings and/or recovery of funds. Responsible for providing clinical knowledge to the SI team to support both prepayment reviews and/or post-payment investigations.

ESSENTIAL FUNCTIONS:

+ Review of medical records and claims. Investigate potential fraud and over-utilization by performing complex medical reviews of claims and medical records. The claims may be in a pre or post payment environment. Provide a detailed but concise analysis to communicate findings about the ability to pay or deny a claim or claim lines using clinical and/or coding, billing, or reimbursement knowledge. Maintain appropriate records and supporting documentation regarding findings in accordance with departmental standards. Process all assigned claims or batch case reviews within departmental and communicated timelines.

+ Provide support to investigative teams as they perform all levels of healthcare fraud, waste, and abuse investigations. Oral, written, and other communication skills are used to effectively accomplish the various tasks associated with case investigations including the ability to communicate technical clinical information to non-clinical individuals. Collaborate with investigative teams to correlate review findings with appropriate actions (e.g., provider education through original, complex, and technical letters, meeting and negotiating with providers, recoveries of monies, recommending network de-selection referrals to State and/or Federal Agencies to effect changes in the providers/facilitys practice.

+ When assigned act as liaison/consultant inside corporation on cases, in cooperation with areas such as Medical Policy, Legal and Legislative Affairs, Claims Processing Areas, Customer Service Operations, Provider Representatives, Credentialing, Contracting, Appeals and Grievances, and Utilization Management. This may include notification to above areas of problem providers/facilities, recommending changes to system edits, requesting modifications to medical policy and respective changes to on-line policy edits, and educating the above areas regarding appropriate claims processing for a particular provider/facility or service.

+ When assigned acts as liaison/consultant to agencies outside the corporation, developing cases in cooperation with Boards of Medicine, local medical societies, and State and/or Federal agencies including Office of the Inspector General, Office of Personnel Management, and Federal Bureau of Investigations. Assists outside agencies by gathering data and medical documentation for subpoenas, responds to attorney inquires and requests, and testifies in State and/or Federal courts when required. Investigates and resolves individual member inquiries and complaints related to over-utilization or potential fraud by health care providers/facilities.

+ Perform special projects to meet the objectives of the Special Investigations Unit.

QUALIFICATIONS:

**Education Level:** Bachelor's Degree OR in lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience.

**Experience:** 5 years or its equivalent in nursing.

Licenses/Certifications Required Upon Hire:

+ RN - Registered Nurse - State Licensure And/or Compact State Licensure

+ Coding certification such as Certified Professional Coding (CPC) or higher

Knowledge, Skills and Abilities (KSAs)

+ Knowledge of patient rights and laws relative to those rights, such as HIPAA.

+ Skill in monitoring/assessing the performance of self, other individuals, or organizations to make improvements or take corrective action.

+ Excellent communication skills both written and verbal.

+ Ability to build comprehensive reports and effectively convey information to others.

Salary Range: $67,464 - $133,991

Salary Range Disclaimer

The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilities of the position, the candidate's work experience, education/training, internal peer equity, and market and business consideration. It is not typical for an individual to be hired at the top of the range, as compensation decisions depend on each case's facts and circumstances, including but not limited to experience, internal equity, and location. In addition to your compensation, CareFirst offers a comprehensive benefits package, various incentive programs/plans, and 401k contribution programs/plans (all benefits/incentives are subject to eligibility requirements).

Department

SIU Government Programs - Medi

Equal Employment Opportunity

CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.

Where To Apply

Please visit our website to apply: www.carefirst.com/careers

Federal Disc/Physical Demand

Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.

PHYSICAL DEMANDS:

The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted.

Sponsorship in US

Must be eligible to work in the U.S. without Sponsorship.

\#LI-LY1

REQNUMBER: 21709