Medical Investigator I/II (RN Required)

SIU Medical Investigator

Under the guidance of the SIU Management, this position is responsible for the accurate and thorough clinical investigation of potential fraud, waste and abuse (FWA) for all lines of business. The scope of accountability includes investigating and remediating allegations of FWA while adhering to compliance and regulatory requirements. Primary activities include substantiating referrals, case planning and research, conducting onsite or desk audits, clinical reviews of medical records to ensure correct billing of services and appropriateness of care, interviewing potential witnesses, developing corrective action plans, developing correspondence to impacted parties, managing disputes, and collaborating with law enforcement and regulatory agencies.

Essential Accountabilities:

• Functions as a clinical reviewer of medical records, researching and investigating complex medical cases. Interprets a variety of documents including, but not limited to provider contracts, group benefit structures, Corporate Medical Policies, the AMA CPT Coding Guidelines, HCPCS coding, inter-plan regulations, government policies, as well as diverse regulatory and legal requirements.
• Thoroughly researches allegations or issues and develops sources of information to create a plan of action, accumulates sufficient detailed evidence including statements, documents, records and exhibits. Evaluates situations accurately and interacts with management, medical directors and legal, where appropriate, to ensure complex issues are addressed appropriately.
• Prepares comprehensive summary reports and assures accuracy of information provided to providers, regulators, law enforcement, Legal, Compliance and outside counsel. Prepares cases for prosecution, civil settlement, or overpayment recoupment by documenting findings in a clear and concise manner.
• Analyzes proactive detection reports and claims data to identify red flags/aberrant billing patterns.
• Manages cases as assigned, prioritizing case load as appropriate. Maintains case logs, prepares records and regular status reports. Interacts with health care providers, often under adverse conditions due to discovery of potential FWA. Discusses sensitive material in a professional, fair and accurate manner. Recommends providers for referrals to the New York State Office of Professional Medical Conduct Office of Professional Medical Conduct/NYS Education Department, Office of Professional Discipline and/or internal referral for quality review by the applicable business area.
• Acts as primary point of contact with law enforcement for assigned cases and may be required to prepare files and testify in court, as needed, in matters regarding litigation related to their reviews.
• Prepares recommendations on preventive/corrective measures for the deterrent of future fraud.
• Supports other SIU investigators and analysts with their cases by providing clinical information/expertise and as necessary, performs clinical reviews of medical records.
• Consults with external practitioners, medical professional groups and agencies, professional medical associations, the BlueCross BlueShield Association, the Food and Drug Administration (FDA), and Centers for Medicare and Medicaid Services (CMS). Provides routine interaction and coordination with the BCBS Association National Anti-Fraud office, BC/BS Plan SIUs, FEP, CMS, DOH, OMIG, MFCU, local, state and federal law enforcement and prosecutorial agencies and medical licensing boards.
• Maintains accurate and up-to-date knowledge of all Government Programs regulations (Medicaid, Medicare, Federal Employee Program, New York State Department of Financial Services, etc.).
• Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies' mission and values, adhering to the Corporate Code of Conduct, and leading to the Lifetime Way values and beliefs.
• Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures.
• Regular and reliable attendance is expected and required.
• Performs other functions as assigned by management.

Level II (in addition to Level I Accountabilities)

• Performs more complex investigations with less direct supervision. Performs compliance and/or governance on more complex special projects and audits.
• Offers process improvement suggestions and participates in the solution of more complex issues/activities.
• Provides and supports training or reference materials for internal team members as appropriate.
• Consistently provides accurate, organized and well written audit results with minimal assistance from management.
• Oversees and coordinates the daily activities of the non-clinical SIU staff medical record reviews.
• Keeps abreast of new developments in the field of medical technology through medical literature research, participation in seminars, monitoring professional society websites, etc.
• Mentors new/junior staff and assists with coaching, whenever necessary.
• Participates on committees.

Level III (in addition to Level II Accountabilities)

• Manages the highest level of complex investigations, compliance and regulatory issues and exercises decision-making in project work groups.
• Assesses potential non-compliance vulnerabilities, identifies root causes of issues and provides practical business recommendations for corrections. Works with business area staff, Compliance, and other internal departments as necessary to develop recommendations and reach meaningful and appropriate resolutions.
• Serves as a subject matter expert and liaison for interdepartmental projects and represents non-clinical staff in discussions with Medical Directors and/or clinical consultants.
• Serves as an internal auditor/peer reviewer for new clinical staff, as needed.
• Mentors (to others in the department), provides coaching, guidance and leadership for daily activities of the SIU clinical staff. Acts as a resource to staff members.
• Provides back-up for Supervisor/Manager, whenever necessary.

Minimum Qualifications:

• Must meet the NYS DFS's and the NYS OMIG's minimum investigator requirements as follows: Persons employed by the SIU as investigators shall be qualified by education or experience, which shall include: A minimum of five years in the healthcare field working in FWA investigations and audits; or five years of insurance claims investigation experience or professional investigation experience with law enforcement agencies; or seven years of professional investigation experience involving economic or insurance related matters; or an associate's or bachelor's degree in criminal justice or related field; or employment as an investigator in the SIU on or before December 28, 2022.
• Current NYS R.N. license with a minimum of three years clinical experience; medical/surgical background preferred.
• Current CPC designation or must obtain CPC designation within one year of hire date.
• Knowledge of medical record coding conventions (e.g. CPT, DRG, HCPCS, ICD10, etc.).
• A general understanding of contract benefits, electronic data processing systems, and organizational policies and procedures.
• Demonstrates excellent oral communication skills and proficient writing skills for the creation of comprehensive professional documents.
• Demonstrates proficient computer skills in Word, Excel, Internet, and email.
• Ability to multi-task and balance priorities.
• Excellent interpersonal skills.

Level II (in addition to Level I Qualifications)

• Two or more years of experience in the Medical Investigator role.
• Expertise in the technology of the job.
• Excellent understanding of contract benefits, electronic data processing systems, and corporate policies and procedures.
• Excellent ability to determine State and Federal fraudulent activity and compile necessary documentation for prosecution presentation. Ability to explain and interpret these findings to law enforcement authorities in a comprehensive manner.
• Excellent dispute resolution and negotiation skills in order to interface appropriately with many different provider types, attorneys, other Blue Plans and external agencies and business partners.
• Demonstrated superior oral communication skills, strong presentation skills, and strong writing skills for the creation of comprehensive professional documents.
• Proficient with health systems operations including an understanding of reimbursement methodologies and coding conventions for governmental and commercial products (e.g., Medicare, Medicaid, CPT, HCPCS, ICD10, DRG, APC, RBRVS, etc.).
• Extensive experience with claims processing systems, claims flow, adjudication process, system edits and display screens.

Level III (in addition to Level II Qualifications)

• Five or more years in a Medical Investigator role.
• Subject matter expert in health systems operations including an understanding of reimbursement methodologies and coding conventions for governmental and commercial products (e.g., Medicare, Medicaid, CPT, HCPCS, ICD10, DRG, APC, RBRVS, etc.).
• Comprehensive understanding of multiple functional areas (i.e., SIU, Legal, Regulatory, Operations) and supporting systems. (BREADTH).
• Expertise in complex clinical coding/reviewing assignments, difficult investigations and highly visible issues. (DEPTH).
• Lead the training of new staff and provide feedback to management