20 days old

SIU Specialist

Magellan Health
San Diego, CA 92101
  • Job Code
    R00000037425
Responsible for the intake and initial handling of allegations of fraud, waste or abuse. Conducts preliminary investigation to assess the merit of an allegation through fact gathering and analysis of data. Uses independent judgment to conclude preliminary investigation in accordance with procedures or to present to management to recommend for audit or investigation referral to DHCS. Maintains confidentiality and compliance with HIPAA privacy requirements and applicable state and federal regulations.
FRAUD, WASTE AND ABUSE DETECTION:
  • Maintains caseload of incidents with low to medium priority and complexity.
  • Prioritize and manage workload to meet internal performance metrics, regulatory and contractual requirements.
  • Analyze data to find suspicious patterns and outliers using knowledge of healthcare coding conventions, fraud schemes, and general areas of vulnerability.
  • Contact referrer, member, provider, or witnesses to gather additional information, facts and supporting documentation.
  • Collaborate and refer non-SIU related issue and activities to external departments (Cost Containment, Networks, Clinical, Medi-Cal Rx Compliance)for handling.

PACKAGING OF FINDINGS AND RECOMMENDATIONS:

  • Organize data and document preliminary investigative steps with a high level of detail and accuracy, to clearly and concisely support conclusions and recommendations.

MISCELLANEOUS DUTIES:

  • Provide backup support to team members (SIUInvestigator andSIU Clinical Pharmacist Reviewer) in the performance of job duties as assigned.
  • Successfully complete required training sessions and continuing education credits.
  • Other duties as assigned.

Other Job Requirements

Responsibilities

  • 3+ years' fraud investigations/claims experience.
  • Ability to manage workload while simultaneously working on multiple projects and cases with timely and accurate results with limited supervision.
  • Demonstrated strategic and analytical abilities to review and evaluate information such as claims data, suspicious patterns and other supporting information related to case allegation.
  • Requires the verbal, written and interpersonal skills to effectively interact and communicate conclusions and recommendations to management and customers.
  • Proficient with Microsoft Office Word, Excel and PowerPoint with ability to quickly learn and use new software applications.
  • Knowledge of ICD-9/10, CPT/HCPS/Revenue codes, insurance terms and policy interpretation.
  • CFE - Certified Fraud Examiner credential preferred.
  • Bachelor's degree preferred.
  • Prefer knowledge of managed health care business model and processes, preferably in behavioral health, radiology or pharmacy.

General Job Information

Work Experience
Claims, Fraud Investigations

Education
Bachelors

License and Certifications - Required

License and Certifications - Preferred
CFE - Certified Fraud Examiner - Enterprise

Magellan Health Services is proud to be an Equal Opportunity Employer and a Tobacco-free workplace. EOE/M/F/Vet/Disabled. Every employee must understand, comply and attest to the security responsibilities and security controls unique to their position.





Posted: 2020-10-04 Expires: 2020-11-02
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SIU Specialist

Magellan Health
San Diego, CA 92101

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