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HealthPartners Medical Review Investigator in St Paul, Minnesota

Medical Review Investigator

  • Job ID:

57287

  • Department:

Claims Dept

  • City:

St Paul, MN

  • Location:

HP - St Paul 180 East Fifth

  • Position Type:

Full-Time

  • Anticipated Work Schedule:

Monday - Friday

Business Hours

  • Hrs/Pay Period:

80

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Job Description:

We currently have an exciting opportunity for a Medical Review Investigator. This role supports and maintains the clinical review/medical review function for the Claims or Fraud and Abuse area. They investigate cases related to providers and enrollees of Medicaid, Medicare, and Commercial fully and self-insured products. Provide analysis of claims processing and medical review protocols. Serve as liaison with physician advisors and vendors to communicate medical review and/or Fraud and Abuse Unit policies and procedures. This position includes the responsibility for managing and tracking impacted claims throughout the investigative process, and working with the Fraud and Abuse Manager on investigations. At HealthPartners, you’ll find a culture where we live our values of excellence, compassion, integrity and most importantly, partnership. By working together, we will improve health and well-being, create exceptional experiences for those we serve and make care and coverage more affordable.

ACCOUNTABILITIES:

  • Triage claims and claims documentation to identify potential Fraud and or Abuse.

  • Investigate cases related to providers and enrollees of Medicaid, Medicare, and Commercial fully and self-insured products.

  • Perform site visits of providers.

  • Conduct interviews of professionals, witnesses and patients/members.

  • Conduct License checks on professionals.

  • Prepare investigative file for Clinical Review.

  • Develop and maintain tracking system to evaluate and report on review program effectiveness and cost savings. Identify areas that need to be changed or improved.

  • Work with staff and non-staff providers to gather medical information on referral claims and/or potential fraud and abuse cases.

  • Identify new procedures and technologies utilized in claims submitted. Develop and implement the review criteria to address new services.

  • Prepare final investigation reports for HP legal and subsequent referral to outside agencies.

  • Communicate results of medical review to members and providers when appropriate.

  • Report and provide assistance as requested to regulators of Medicaid, Medicare, and Commercial fully and self-insured products

  • Develop and coordinate the guidelines for fraud detection investigation.

  • Responsible for an investigative caseload. Accurately and thoroughly manage receipt, tracking and reporting of all case work in a timely manner. Monitor case referral volume.

REQUIRED QUALIFICATIONS:

  • Bachelor’s degree in relevant field, or 4-7 years of Investigative Experience

  • Two years’ experience in utilization review or medical field.

  • Advanced knowledge of health insurance industry and regulatory requirements affecting managed care.

  • Detailed knowledge of coding nomenclature and guidelines.

  • Concise and accurate written communication skills.

  • Excellent oral presentation skills.

  • Demonstrated leadership skills.

  • Effective human relations skills at an internal/external organizational levels.

  • Excellent planning and organizing skills.

  • Advanced analytical ability to assess situations and choose cost-effective solutions.

  • Ability to work and make logical decisions independently.

  • Demonstrated good judgment and investigative skills when reviewing potential fraud and abuse cases to identify schemes and likely cases.

  • Understanding and compliance with regulatory guidelines pertaining to fraud and abuse program requirements.

PREFERRED QUALIFICATIONS:

  • 2 years’ experience in claim fraud and abuse investigations.

  • Experience with HMO, fully insured, ASO and Indemnity products as well as government programs.

  • Prior experience in developing medical review programs.

  • Proficient with personal computers, word processing and spreadsheets.

HealthPartners is recognized nationally for providing outstanding care and experience for patients and members. We offer an excellent salary and benefits package. For more information and to apply go to www.healthpartners.com/careers and search for job ID #55788.

Additional Information:

We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class.

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