Resp & Qualifications
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.
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 provider’s/facility’s practice.
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.
RN - Registered Nurse - State Licensure And/or Compact State Licensure Active - Upon Hire Required
Coding certification such as Certified Professional Coding (CPC) or higher - Preferred
Experience: 5 years or its equivalent in nursing.
Knowledge, Skills and Abilities (KSAs)
Department: Special Investigations Unit
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.
Hire Range Disclaimer
Actual salary will be based on relevant job experience and work history.
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.
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
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