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Company Name : AlohaCare
Location : Honolulu, HI 96814
Position : Special Investigations Unit (SIU) Investigator
Job Description : The Company: AlohaCare is a local, non-profit health plan serving the Medicaid and Medicare dual eligible population. We provide comprehensive managed care to qualifying health plan members through well-established partnerships with quality health care providers and community-governed health centers. Our mission is to serve individuals and communities in the true spirit of aloha by ensuring and advocating access to quality health care for all. This is accomplished with emphasis on prevention and primary care through community health centers that founded us and continue to guide us as well as with others that share our commitment. As Hawaii’s third-largest health plan, AlohaCare offers comprehensive prevention, primary and specialty care coverage in order to successfully build a healthy Hawaii.The Culture: AlohaCare employees share a passion for helping Hawaii’s most underserved communities. This passion for helping and caring for others is internalized and applied to our employees through a supportive and positive work environment, healthy work/life balance, continuous communication and a generous benefits package.AlohaCare’s leadership empowers and engages its employees through frequent diversity, recognition, community, and educational events and programs. AlohaCare has a strong commitment to support Hawaii’s families and reinforces a healthy work/home balance for its employees. Because AlohaCare values honesty, respect and trust with both our internal and external customers, we encourage open-door, two-way communication through daily interactions, employee events and quarterly all-staff meetings. AlohaCare’s comprehensive benefits package includes low cost medical, dental, drug and vision insurance, PTO program, 401k employer contribution, referral bonus and pretax transportation and parking program.These employee-focused efforts contribute to a friendly, team-oriented culture which is positively reflected into the communities we serve.The Opportunity: The SIU Investigator is responsible for detection, identification, investigation and prevention of healthcare fraud, waste, and abuse as well as compliance investigations, including HIPAA privacy incidents. The SIU Investigator will utilize claims data within the SIU application, regulatory guidance and policies, and other sources to identify aberrant billing practices and other patterns. This position supports regulatory compliance activities including regulatory reporting, investigations and training and education requirements. Under general supervision, responsible for compiling, verifying and submitting reports, and analyzing general compliance, FWA and privacy incidents. Performs applicable follow up on corrective actions that result from compliance activities to ensure compliance with applicable federal and state laws, contract requirements, and internal policies and procedures.Provides high quality customer service using professionalism, confidentiality and good judgment. The SIU Investigator is responsible for maintaining and fostering an environment that enhances and promotes regulatory compliance.Primary Duties and Responsibilities: Conducts Fraud, Waste and Abuse (FWA) and related compliance investigations.Develops and maintains routine and ad hoc Compliance reporting, conducts detailed analysis, and summarizes results for internal and external stakeholders.Analyzes compliance and FWA cases for root cause, trends and tracks data to translate findings and develop processes for improvement or investigation.Prepares accurate, timely, unbiased and detailed written reports and case summaries in compliance with corporate standard operating procedures and guidelines documenting investigative results.Updates corporate SIU case management system with accurate, current, and thorough investigative notes, reports and summaries.Independently develops and executes appropriate investigation strategy for assigned cases. Leads in-depth interviews of participants, witnesses or affected parties.Completes detailed and extensive investigations in adherence with AlohaCare’s procedures and best practices. Gathers and secures evidence and makes determinations regarding potential recoveries.Conduct reviews of flagged claims and suspected FWA, identifying opportunities for improving payment accuracy and preventing FWA.Review claims flagged by Vendor with do not pay recommendations and suspected FWA cases in an accurate, efficient and timely manner.Conduct outreach to physicians and office staff for medical records when needed to support review of flagged claims;Prepare referrals for preliminary investigations, including but not limited to: Requesting medical records, creating forms, reports and updating logs.Assist other compliance investigators with preliminary investigation activityCommunicates investigation outcome to line of business personnel and partners to implement provider and other compliance/ SIU related edits when appropriate.Proactively partners with line of business personnel to generate referrals. Partners with various SIU and line of business personnel to determine merits of initiating organized scheme investigations.May evaluate incoming referrals to determine appropriate SIU investigation assignments. Researches and prepares cases for clinical and legal review.Participates and reports (as needed) in Fraud, Waste, Abuse Committee (FWAC).Provides fraud awareness training to internal stakeholders. Provides on the job training to new Investigators and provides guidance for less experienced or skilled Investigators. Assists Investigators in identifying resources and best course of action on investigationsFacilitates the recovery of inappropriate payments as a result of fraud matters.Assists in maintaining compliance with timely completion and reporting of State and Federal deliverablesCooperates with federal, state, and local law enforcement agencies in the investigation and prosecution of healthcare fraud and abuse matters. May be required to provide testimony during civil and criminal proceedings.May represent the Company and actively participate in industry association meetings by providing training to industry SIU personnel or law enforcement. Shares intelligence and trends with SIU and other internal stakeholders.Delivers presentations to internal and external customers on Fraud, Waste and Abuse and related subjects.· Responsible for maintaining AlohaCare’s confidential information in accordance with AlohaCare policies, and state and federal laws, rules and regulations regarding confidentiality. Employees have access to AlohaCare data based on the data classification assigned to this job title.Required Competencies & Qualifications: · Bachelor’s Degree in related field of study or combination of education, professional training and/or work experience which demonstrates the capability to perform the functions of the position· 1-3 years of related SIU Investigator experience· Must possess strong knowledge of healthcare billing / coding, health insurance reimbursement methodologies, including ICD-10 and HCPCS coding.· Excellent written and verbal communications skills required. The ability to obtain information from others and deliver information in a concise and clear manner is critical· Strong analytical abilities to review and evaluate information such as claims data, patterns and other supporting information related to case allegations details.Strong proficiency in Excel with the ability to effectively decipher, analyze, and organize complex data. Intermediate level of knowledge with local, state/federal laws and regulations pertaining to healthcare fraud, waste, and abuse.· Flexibility to work independently with self-initiative and yet be collaborative and team-minded in a fast-paced and deadline sensitive team structure· Ability to work with minimal supervision· Curious, detailed-oriented and mindset required· Research skills· Excellent organizational and time management skills required· Excellent computer skills required. The ability to navigate and understand claims data and various database in order to develop and document case allegations is required.· Strong problem-solving and decision –making skills to work through challenging and complex case details required· Proficient knowledge of spreadsheets/graphics, presentation, and databases· Working knowledge of Microsoft Access, Excel, Word, and PowerPoint· Understanding of investigational processes and standards· Strong analytical skills, communication skills, and relationship skills· Ability to work on multiple projects concurrently and prioritize tasks appropriately· Ability to define problems, collect data, establish facts, and draw valid conclusions. Ability to interpret an extensive variety of technical instructions and deal with several abstract and concrete variables.Preferred Requirements: Proficiency in business intelligence software and reporting tools including, but are not limited to, MS SQL Server Components and Microsoft SQL, Oracle, and Business Objects (Crystal Reports, Web Intelligence, OLAP, Universes and Xcelsus)Strong claims knowledge is beneficialAbility to write reports and create workflowsAbility to effectively present information and respond to questions from groups of managers, clients, customers, and the general public.Certified in Professional Coder (CPC) is a plus.Demonstrated knowledge and experience of Medicare, Medicaid, and other government programs.Mental, Physical and Environmental Demands: · Sedentary Work: Exerting up to 20 pounds of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time.· Inside working conditions· No environmental hazards· Requires operation of general office equipment to include PCAlohaCare is committed to providing equal employment opportunity to all applicants in accordance with sound practices and federal and state laws. Our policy prohibits discrimination and harassment because of race, color, religion, sex (including gender identity or expression), pregnancy, age, national origin, ancestry, marital status, arrest and court record, disability, genetic information, sexual orientation, domestic or sexual violence victim status, credit history, citizenship status, military/veterans status, or other characteristics protected under applicable state and federal laws, regulations, and/or executive orders.Job Type: Full-timePay: From $57,000.00 per yearBenefits:401(k)401(k) matchingDental insuranceEmployee assistance programFlexible spending accountHealth insuranceLife insurancePaid time offReferral programVision insuranceSchedule:8 hour shiftDay shiftMonday to FridayAbility to commute/relocate:Honolulu, HI 96814: Reliably commute or planning to relocate before starting work (Required)Education:Bachelor’s (Required)Experience:related SIU investigator: 1 year (Required)healthcare billing and coding: 1 year (Preferred)License/Certification:Certified Professional Coder (Preferred)Work Location: One location
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