FRAUD & ABUSE INVESTIGATOR II

Job Snapshot

Job ID: 52707

Location: Linthicum Heights, MD

Posted: 8/31/2017

Category: Research, Professional Services

Experience: 1 to 2 years

Education: See Requirements

Job Description

ABOUT THE POSITION

We are currently seeking a dynamic Fraud & Abuse Investigator II to join our team at our office in Linthicum, Maryland.  The Fraud & Abuse Investigator will be responsible for conducting pre-payment, post payment and routine provider audits.

Position Responsibilities:

  • Under general direction, independently conducts audits and other reviews of medical and billing records to determine whether services were medically necessary and rendered in accordance with Public Behavioral Health System (PBHS) requirements. 
  • Evaluates the quality of the assessment, diagnosis, treatment/services planning and services delivered. 
  • Conducts investigations of reported, alleged or suspected fraud involving the full range of products at Beacon Health Options 
  • Ensure compliance with contractual requirements related to Special Investigative units and fraud and abuse and waste investigations. 
  • Conducts detailed audits from review of billing, clinical and other records comparing with company contracts and policy as well as medical necessity and quality of care standards. 
  • Handle and lead complex investigative cases as well as day to day activities of the unit during senior management absence. 
  • Recommendations for action based on findings.
  • Timely completion of written audit reports.
  • Performs other duties as assigned

Position Requirements:

Education: Master’s licensed clinician or nurse with 1-2 years of experience required.

Licensure:  Maryland licensed; Graduate level or higher; if graduate level licensure 1-2 years’ experience required (LGSW, LCSW, LCSW-C, LGPC, LCPC, LCADC, LGADC)

Relevant Work Experience:   Minimum of 3 years’ experience in healthcare, nursing, accounting, law enforcement or healthcare coding and auditing, with at least 1-2 years QI or clinical experience including knowledge of clinical treatment, quality improvement procedures, state requirement or managed care, preference given to candidates with this experience in a managed care environment. 1-2 years’ experience with healthcare fraud and abuse investigations preferred.

Knowledge, Skills & Abilities:

  • Strong financial auditing and analytical skills, as well as strong knowledge of healthcare coding and medical record documentation requirements.
  • Demonstrates initiative and pro-active in problem resolution.
  • Knowledge of state and federal guidelines and regulations.
  • Demonstrated ability to interact with individuals at all levels of the organization and external sources (i.e. state, federal and local law enforcement agencies.

TO APPLY

Click below on “Apply for this Position” to create a profile and apply for the position

Beacon Health Options company is proud to be an Equal Opportunity and Affirmative Action Employer as well as a Drug Free and Tobacco Free Work Environment. EOE/AA/M/F/Veterans/Disabled

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Job Requirements

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  • 5,000 employees nationally and in the U.K.,serving more than 48 million people.
  • My team at Beacon Health Options welcomed me immediately. Collaborating with so many talented individuals within the organization gives me a daily opportunity to see the great work we do in action. - Proposal Specialist, Norfolk, VA
  • Over 350 clients, including 225 employer clients, 45 Fortune 500 companies and partnerships with almost 100 health plans
  • What I like most about Beacon is that the people who work here are smart and dedicated to the company's mission. Beacon is at the forefront of changing mental healthcare delivery, so the work is exciting and meaningful. - Analyst, Boston, MA
  • Serving 8.5 million military personnel, federal civilians and their families.