Associate Fraud and Abuse Investigator/Certified Professional Coder (CPC) - Remote!

City/State

Work Shift

• →Responsible for contributing to in-depth investigations for suspected fraud or abuse with respect to provider, pharmacy, employer, member, and broker interactions involving the full range of products.
• →Responsible for contributing to the review of the quality of pharmacy, physician, ancillary and hospital based coding in routine desk audits as well as occasional on-site audits.
• →Contribute to the review of reimbursement systems relating to health insurance claims processing and ensures adherence to policies and procedures for its various product offerings.
• →Specific progression of responsibility is a follows dependent upon education, certifications, and experience:

- Triage and prioritize leads/member complaints from internal sources.

- Review and assess incoming referrals; Assist in the investigation of potential fraud, waste, and abuse.

- Conduct research in support of an investigation.

- Collect and evaluate potential suspicious patterns in claims data, provider enrollment data, and other sources and refers to Investigator for investigation or settlement.

- Assures accurate reimbursement is obtained and coding practices are compliant.

- Maintain comprehensive case files.

- Participates in special projects as required.

• Bachelor's Degree REQUIRED OR
• Minimum of 2 years combined experience required in Medical Coding OR Healthcare (Medical Chart Review/Insurance Billing) OR Internal/External Audit OR Regulatory/Compliance OR Claims Investigations OR Criminal Investigation/White Collar Crime REQUIRED

• Certified Professional Coder (CPC) REQUIRED (or achieved within 12 months of hire date)
• Certified Fraud Examiner (CFE) OR Accredited Health Care Fraud Investigator (AHFI) preferred.

• Job skills: Professional Writing, Verbal Communication, Time Management, Complex Problem Solving/Critical Thinking, Microsoft Excel and Word, Microsoft Access and Outlook

Talroo-Health Plan

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Alabama, Delaware, Florida, Georgia, Idaho, Indiana, Kansas, Louisiana, Maine, Maryland, Minnesota, Nebraska, Nevada, New Hampshire, North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Washington, West Virginia, Wisconsin, and Wyoming.