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Commonwealth Care Alliance FWA Investigator Coder Sr. Associate (Remote) in Boston, Massachusetts

Why This Role is Important to Us:

Position Summary:

The FWA Investigator Coder Sr. Associate is an integral part of the Fraud, Waste & Abuse (FWA) Special Investigation Unit (SIU). The position reports directly to the Sr. Director, Fraud, Waste & Abuse. This position utilizes a variety of FWA investigative tools and techniques to complete activities required to identify compliance with state and federal results, regulations, and requirements.

This position is responsible for completing a variety of program integrity reviews and activities within their required timeframes. This role requires effective communication with providers, and other CCA departments related to review processes and results. Sr Associate, FWA Investigator Coder utilizes claim analysis, document review, coding knowledge and applies FWA tools to create, maintain and summarize review findings that are timely, accurate and well documented.

This position is responsible for conducting analysis to identify trends related to potentially inappropriate submission of claims by providers and collaborates with other team members and areas in making recommendations for payment integrity. This may include making recommendations for Payment policies, system enhancements, and prepay edits. The FWA Sr. Investigator Coder will be proficient at each step of the review process including internal/external communication, medical record documentation review, application of regulations and identification of submitted codes not supported by medical record documentation.

Supervision Exercised:

No, this position does not have direct reports.

What You'll Be Doing:

Essential Duties & Responsibilities:

  • Conduct prospective medical record review of claims as part of a prepayment review process or conduct claim reviews retrospectively to determine if medical record documentation supports services billed.

  • Write concise and accurate Memorandum of Findings for retrospective reviews identifying scope, findings, and recommendations.

  • Review and analyze internal and external referrals, claims and associated medical records to identify appropriateness of coding, care, sufficiency of documentation and compliance with health care regulations.

  • Identify trends and concerns related to potential inappropriate submissions of claims by participating providers.

  • Document and track activity in internal database, provide case updates on progress of investigation, and coordinate with management recommendations and further actions and/or resolutions.

  • Maintain and update cases in FWA case management database within prescribed timeframes.

  • Participate in training programs to develop a thorough understanding of FWA related materials. Provide detailed explanations to internal and external stakeholders on findings, to answer questions, and provide clarity on FWA policies and Standard Operating Procedures (SOP).

  • Interface with providers regarding compliance with federal, state, county and contractual regulations and obligations.

  • Utilize data mining and visualization programs to design queries and analyze claims data to detect outliers or suspicious patterns for further review.

  • Conduct detailed research to identify and apply appropriate regulatory, contractual and industry requirements to the different benefits and products within investigations.

  • Proactively seek out and develop leads, resources, and opportunities from a variety of sources, and develop and maintain relationships with enterprise, industry, law enforcement and other contacts.

  • Testify in court, as necessary.

  • Maintain confidentiality of all provider and member sensitive information reviewed.

Working Conditions:

  • Standard office conditions.

What We're Looking For:

Required Education:

  • Bachelor’s Degree or equivalent experience

Required Experience:

  • CPC medical coding background

  • Proficiency in Microsoft Office (Word, Excel, PowerPoint, and Access).

Desired Experience:

  • Prior experience in health care compliance, regulation, SIU, government agency or similar position related to data analysis or an insurance-related field beneficial.

  • Background and experience in facility coding.

Required Knowledge, Skills & Abilities:

  • Experience and knowledge of CPT Coding, including a CPC or similar Coding designation.

  • Strong knowledge of standard industry coding guidelines such as CPT, HCPCS, ICD 10 and NCCI.

  • Ability to independently develop and present verbal and written investigative and management reports.

  • Knowledge of federal and state laws and regulations pertaining to fraud, waste and abuse.

  • Desire to work in a collaborative and fast-paced team environment.

Required Language:

  • English

EEO is The Law

Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled

Please note employment with CCA is contingent upon acceptable professional references, a background check (including Mass CORI, employment, education, criminal check, and driving record, (if applicable)), an OIG Report and verification of a valid MA/RN license (if applicable). Commonwealth Care Alliance is an equal opportunity employer. Applicants are considered for positions without regard to veteran status, uniformed service member status, race, color, religion, sex, national origin, age, physical or mental disability, genetic information or any other category protected by applicable federal, state or local laws.