Description About SCAN SCAN Group is a not-for-profit organization dedicated to tackling the most pressing issues facing older adults in the United States. SCAN Group is the sole corporate member of SCAN Health Plan, one of the nation's leading not-for-profit Medicare Advantage plans, serving more than 300,000 members in California, Arizona, Nevada, Texas and New Mexico. SCAN has been a mission-driven organization dedicated to keeping seniors healthy and independent for more than 45 years and is known throughout the healthcare industry and nationally as a leading expert in senior healthcare. SCAN employees are a group of talented, passionate professionals who are committed to supporting older adults on their aging journey, while also innovating healthcare for seniors everywhere. Employees are provided in-depth training and access to state-of-the-art tools necessary to do their jobs, as well as development and growth opportunities. SCAN takes great pride in recognizing our team members as experts in their fields and rewarding them for their efforts. If you are interested in becoming part of an organization that is innovating senior healthcare visit or follow us on LinkedIn, Facebook, and Twitter. The Job The Senior Investigator position reports directly to the SIU Strategic Project Professional. The successful candidate will work to identify, mitigate, and prevent improper payments by conducting thorough fraud, waste, and abuse investigations and recommending internal and external actions to remediate identified issues. You Will Lead fraud, waste, and abuse investigations and develop corrective actions, including recovering overpayments, drafting provider education, and recommending internal controls to prevent improper payments as appropriate. Analyze data to identify potential billing aberrancies or fraudulent patterns that require additional investigation. Perform desk audits of medical records and facilitate medical necessity reviews by SCAN Medical Directors. Conduct member and provider interviews. Document all investigative actions in the case management system. Head meetings with operational departments, business partners, and regulatory partners. Draft regulatory fraud, waste, and abuse referrals to federal and state Medicare/Medicaid agencies. Establish and maintain relationships with Federal and State law enforcement agencies, task force members, SIU staff, and external contacts involved in investigations. Develop educational materials for internal staff on healthcare fraud, waste, and abuse and the SIU's role within the organization. We seek Rebels who are curious about AI and its power to transform how we operate and serve our members. Actively support the achievement of SCAN's Vision and Goals. Other duties as assigned. Your Qualifications Bachelor's Degree or equivalent experience Preferred Certifications or Licenses: Accredited Health Care Fraud Investigator (AHFI), Certified Fraud Examiner (CFE), Certified Professional Coder (CPC), or other coding credential(s) desired but not required. Experience Preferred: 5 - 7 years of healthcare fraud, waste, and abuse investigations or related experience. Previous Medicare/Medicaid investigations experience. Technical expertise - Advanced analytical skills Problem Solving - Basic problem-solving skills Communication - Good communication and interpersonal skills Working knowledge of health plan operations, claim processing, medical terminology, and coding (CPT, HCPCS, ICD). Proficiency in Microsoft Office with advanced skills in Excel (must know how to do pivot tables). Strong analytical and research skills. Excellent problem solving and decision-making skills with attention to details. Strong verbal and written communication skills. A high degree of integrity and confidentiality is required for handling information that is considered personal and confidential. What's in it for you?
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