SIU case investigation management, resolution and prevention.
- Initiate, analyze, develop, and resolve proactive FWA cases using Fraud Detection Software, advance/extensive knowledge of benefits, claims, rules, processes, and other relevant topics (e.g. medicine, pharmacy, law, accounting)
- Maintain extensive documentation and evidence for SIU cases
- Recommend and implement preventive measures to combat FWA schemes including, but not limited to provider education, policies, claims edits and payment suspensions
- Conduct and lead on-site provider audits and interviews to support complex FWA case investigations
- Manage the recovery, allocation and documentation of health plan funds resulting from FWA findings
SIU Process Improvement and SIU Operational Support
- Perform necessary research and analysis, and recommend improvements and corrective actions for contract, policy, claim-level, and workflow problems proactively identified in case work and other assigned tasks.
- Independently ensures that SIU's needs are being addressed; must be able to clearly articulate business needs so that the department is not negatively affected and elevate concerns and issues to management when applicable.
- Create and maintain internal policies and procedures, workflows and presentations and present as needed to internal and external entities
- Participate in management discussions to improve business processes and control structures.
- Represent SIU at cross functional workgroups and meetings and present case recommendations and preventive solutions to Management and other applicable business areas including, but not limited to Legal, Medical Management, Provider Operations and Claims Operations
- Provide operational oversight to SIU Vendors with delegated FWA functions
- Perform all other miscellaneous responsibilities and duties as assigned or directed.