Special Investigative Analyst
PacificSource

Job Info

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Looking for a way to make an impact and help people?

Join PacificSource and help our members access quality, affordable care!

PacificSource is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, national origin, sex, sexual orientation, gender identity or age.

Diversity and Inclusion: PacificSource values the diversity of the people we hire and serve. We are committed to creating a diverse environment and fostering a workplace in which individual differences are appreciated, respected and responded to in ways that fully develop and utilize each person's talents and strengths.

Position Overview: Assist in identifying potentially fraudulent claims. Review complex claim scenarios for final determinations. Review claim documents (i.e. medical records, operative reports, and diagnostic studies) and prepare documentation for utilization reviews. Determine investigative actions with the leadership team and perform follow-up investigations. Coordinate with law enforcement or state fraud bureaus for regulatory compliance and criminal activity trends. Initiate, analyze and resolve audits of mid to high level complexity in order to present FWA data to the leadership team for tracking and mitigation of exposure. Coordinate efforts to recover erroneous payments made due to processing errors, misrepresentative billing, fraud or abuse.

Essential Responsibilities:

• Analyze quarterly claims reports, training opportunities and FWA by reviewing data for patterns, requesting medical records, reviewing records and developing recommendations and collecting data to present findings to the Claims Leadership Team.
• Work cooperatively with the Grievance & Appeal personnel to review, research and make a determination to approve or uphold the claims processing result based on PacificSource policy and procedures, group/individual contracts and applicable laws governing claims processing.
• Log and research leads of possible fraud waste or abuse. Make recommendations for resolution and work with the FWA workgroup across all lines of business.
• Ability to successfully perform other coding audits to validate correct coding, which includes, but isn't limited to, CPT and HCPCs coding.
• Review claims received through the Advanced Rebill and Compliance queues. These claims require additional research, including, but not limited to the following:
  • Initial clinical evaluations
  • Request and review of medical records
  • Coding assistance and research- CPT and ICD-10, including unlisted procedures and changes in diagnosis and procedures.
  • System editing review.
• Report pertinent information back to the Claims Leadership Team.
• Maintain Certifications in Medical Coding and/or Medical Records Auditing by obtaining needed CE credits.

Supporting Responsibilities:

• Interact with business leaders and users, including external partners and customers as required.
• Maintain professional, service oriented relationships.
• Develop and track project plans for large upcoming projects that affect multiple areas.
• Collaborate with other areas on cross functional tasks.
• Lead and participate in special projects and committees as assigned.
• Ability to judge severity of problems and the need to escalate to management or employ external services.
• Demonstrate ability to organize and prioritize work.
• Demonstrate ability to work independently with minimal oversight.
• Meet department and company standards of performance, attendance and regularly attend team, department and company meetings/huddles.
• Perform other duties as assigned.

Work Experience: Minimum five years claims adjudication at a claims level III or comparable experience preferred. Advanced skills in medical terminology, CPT and ICD-10 coding.

Education, Certificates, Licenses: Requires high school diploma or equivalent. Certified as a Medical Claims Coder and Certified Medical Records Auditor.

Knowledge: Research skills and ability to evaluate situations for appropriate resolution. Ability to read and understand health contracts, benefit language, medical records from both professional and institutional sources.

Has a thorough understanding of PacificSource products, plan designs, provider relationships and health insurance terminology. Has a basic working knowledge of Insurance Division rules and regulations per state. Moderate/high clinical interpretation skills. Thorough understanding of claims processing system and operation. Experience using Microsoft Word/Excel. Advanced keyboard and ten-key skills. Ability to work under time constraints and to quickly understand new information. Team player willing to collaborate with others and help accomplish objectives. Meet or exceed PacificSource performance expectations.

Competencies

• Building Customer Loyalty
• Building Strategic Work Relationships
• Contributing to Team Success
• Planning and Organizing
• Continuous Improvement
• Adaptability
• Building Trust
• Work Standards

Environment: Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 5% of the time.

Our Values

We live and breathe our values. In fact, our culture is driven by these seven core values which guide us in how we do business:

• We are committed to doing the right thing.
• We are one team working toward a common goal.
• We are each responsible for customer service.
• We practice open communication at all levels of the company to foster individual, team and company growth.
• We actively participate in efforts to improve our many communities-internally and externally.
• We actively work to advance social justice, equity, diversity and inclusion in our workplace, the healthcare system and community.
• We encourage creativity, innovation, and the pursuit of excellence.

Physical Requirements: Stoop and bend. Sit and/or stand for extended periods of time while performing core job functions. Repetitive motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English. Communicate clearly and effectively.

Disclaimer: This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times.

This job has expired.