You'll join a high caliber team where you're assisting, educating, problem-solving and resolving tenuous situations to the best possible outcomes. Bring your people skills, emotional strength and attention to detail. In return we offer the latest tools and most intensive training program in the industry. Get ready to start doing your life's best work.(sm)
The Recovery / Resolutions Consultant will be responsible for triaging, investigating and resolving instances of healthcare fraud and/or wasteful and abusive conduct by health care providers who submit claims for payment. This position will be utilizing information from claims data analysis, plan members, the medical community, law enforcement, employee conduct, and confidential investigations in order to document relevant findings. The analyst will conduct onsite and desk audits of provider claims and/or clinical audits (utilizing appropriate personnel) to gather and analyze all necessary information and documentation related to the investigation, and prepare all necessary reports. The analyst will input information into Optum audit workflow tools and the client’s case tracking system. The analyst will act as a subject matter expert in identifying, communicating and recouping improper payments as deemed appropriate. Where applicable, the analyst will provide appeals and investigative support, as well as testimony.
- Investigate, audit, and resolve all types of Medicaid claims as well as recovery and resolution for government payers.
- Process recovery on claims
- Ensure adherence to state and federal compliance policies, reimbursement policies, and contract compliance
- Use pertinent data and facts to identify and solve a range of problems within area of expertise
- The successful candidate will be part of a group of auditors deployed to investigate possible fraud, waste and abuse in Massachusetts
- Generally work is self-directed and not prescribed.
- Works with less structured, more complex issues.
- Serves as a resource to others.