HealthPartners is hiring a Medical Review Investigator. They support and maintain the clinical review/medical review function for the Claims or Fraud and Abuse area. This role investigate cases related to providers and enrollees of Medicaid, Medicare, and Commercial fully and self-insured products. They will 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. They serve as an internal resource for other areas within HealthPartners regarding the Fraud and Abuse Program.

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: (Minimum qualifications needed for this position)

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.