JOB SUMMARY:

The Special Investigation Unit Investigator performs reviews of claim lines flagged by Community's SIU and Community's SIU Contractor. The SIU investigator will assist the SIU manager in gathering information from internal and external partners for investigations and audits. The SIU investigator will coordinate with internal and external resources in determining the appropriateness of codes found in administrative and medical claims and develop reports of findings and recommendations for the SIU function.

JOB SPECIFICATIONS

Essential Functions:
Perform duties associated with SIU prepayment review.
Perform duties associated with Provider self-audits.
Gathering information from internal and external partners for investigations and audits.
Conduct provider and member outreach to obtain documentation and information.
Develop reports of findings and recommendations for the SIU function.
Marginal Functions:
Assist with other duties as needed.

TYPICAL DUTIES THAT MAY BE PERFORMED:

1. Provide timely review and disposition of suspected case referrals, including determination on alleged up coding and our unbundling and communicate with internal and external sources as well as review claim lines flagged by SIU Contractor with do not pay recommendations.
2. Develops and present findings and recommendations regarding the appropriateness of diagnosis and procedure codes submitted on provider service claims, and supports overpayment during discussions with providers and Community's Fraud, Waste and Abuse Committee.
3. Communicate review outcomes and the basis for them effectively and professionally with providers, CHS staff, Fraud Waste and Abuse Committee and other regulatory agencies such as The Office of Inspector General (OIG), Texas Attorney General.
4. Gathers and analyzes data from internal and external resources including claims, data, medical records, contracts, and public record information to determine if further action and an investigation needs to be performed.
5. Educates providers, suppliers, and pharmacies and administrative support staff at all levels on CMS, federal and state statutory, regulatory and contractual requirements, appropriate coding according to AMA guidelines, acceptable practice standards, and procedures for preventing and reporting potential fraud and abuse; Presents educational seminars on fraud and abuse awareness, detection and reporting to areas and departments as required.
6. Ensure the timely reporting of regulatory reports as needed.
7. Actively contributes to achievement of departmental goals, as identified in Department's annual business plan, including specific departmental process improvement plans.
8. Demonstrates Harris Health and Community Health Choice values, including trust, integrity, mutual respect, diversity, responsiveness and caring service.


MINIMUM QUALIFICATIONS:

Education/Specialized Training/Licensure: Bachelor's Degree required.

Must have at least one of the following certifications: CPC/AHFI/CFE (or equivalent) and completion of secondary certification within one year of employment required.

Work Experience (Years and Area): 2 years' experience in healthcare investigations and / or coding in the medical industry directly related to determining appropriate diagnosis, procedure and other codes used in billing for services, utilization management, medical record auditing with degree. Solid Knowledge of Medicare, Medicaid and commercial investigations and coding practices required

Software Proficiencies: Microsoft Office (I.E.: Word, Excel, Outlook)

Claims processing systems preferred.
Other: Certification in Coding and Medical Billing, and Certified Fraud Investigator; Medical coding procedure expertise (CPT, ICD-10, HCPCS) required.