The Clinical Fraud Investigator II is responsible for identifying issues and/or entities that may pose potential risk associated with fraud and abuse through the review of submitted medical record claims. Primary duties may include, but are not limited to: Conducts data mining activities using available tools and internal data warehouse. Performs comprehensive analysis and clinical evaluation of the collected data. Performs in-depth investigations on identified providers as warranted. Examines random claims for compliance with relevant billing and processing guidelines and to identify opportunities for fraud and abuse prevention and control. Researches new healthcare related questions as necessary to aid in investigations. Collaborates with the Special Investigation Unit and other internal areas on matters of mutual concern. Recommends possible interventions for loss control and risk avoidance based on the outcome of the investigation. Coordinates with concerned unit/brand as appropriate regarding approved interventions such as recovery of overpayment, pre-payment audit of claims or putting providers on notice. Assists with training of new associates. Requires an associates Degree in Nursing, 4 years related experience including one year prior experience in WellPoint Clinical Fraud and Abuse Investigation area; or any combination of education and experience, which would provide an equivalent background.
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