Job Summary

This position is under general guidance of the Director, Corporate Compliance and reports directly to the Supervisor, PI Specialist. The PI Support Specialist is responsible for providing claim processing and administrative support for Program Integrity (PI) investigations, law enforcement requests for information, other internal/external Fraud, Waste and Abuse (FWA) case development activities.The PI Support Specialist utilizes healthcare billing, claim processing, and medical record knowledge, in addition to research skills, to review and process of medical/surgical and behavioral health claims according to protocol directions established by PI Specialist. The PI Support Specialist captures savings and recoupment calculations, and reports on PI provider flag efficiencies.The PI Support Specialist compiles claim data, provider contracts, bank accounts, patient files (including, but not limited to medical records and claim images) and other information necessary to respond to law enforcement subpoenas related to FWA investigations. The PI Support Specialist accurately records case referrals, claim activity, and law enforcement information requests, and assists the PI Supervisor with departmental reporting requirements. Ensures strict compliance with court appearance deadlines and HIPAA Privacy Rules.

Key Responsibilities

• Works with PI Specialist to ensure understanding of the case allegations, investigation and findings, and applies understanding to achieve claim review protocol goals.
  • Processes claims, ensuring compliance with contract timeline requirements for claim resolution, meeting defined accuracy metrics.
  •         Creates claim logs to track and analyze claim submissions, and prepares reports for PI Supervisor on efficiencies, savings, and recoupments.
  •         Advises PI Specialist of observed changes in billing patterns.
  •         Recommends process improvements related to all aspects of claims payment and medical documentation requests.
  •         Works with TriWest Data Management, Provider Services, and Legal teams; TriWest vendors; and law enforcement agencies to coordinate timely responses to subpoenas and other requests for investigative assistance.
  •         Compiles and audits document packages, to ensure complete and accurate files that fully satisfy subpoena requirements.

..

•           Responds to incoming hotline calls, and prepares referrals for case development.
•           Researches and resolves inquiries that do not require fraud, waste and abuse investigation.
•           Enters new referral information into case management system and tracks investigative, claim, other internal workgroup, and law enforcement activities through to case resolution.
•           Assists PI Supervisor with required reporting of case referrals, activities, and results.
•           Communicates effectively with management and peers.
•           Identifies and reports any potential quality or fraud issues to management, Quality Management or Program Integrity leadership as appropriate.
•           Performs other duties as assigned.
•           Regular and reliable attendance is required

Education & Experience

Required

o        High School Diploma or GED
o        Healthcare claim processing or billing experience
o        Knowledge of HCFA 1500 and UB-04 claim forms and fields
o        Strong MS Excel skills, to include basic analysis functions

Preferred

• Experience with FACETS claim processing application
  • Knowledge of Fraud, Waste and Abuse investigations
  •         Knowledge of medical record review and documentation requirements
  •         Knowledge of Medicare policies and guidelines
  •         Claim coding experience
  •         Customer Service or Call Center experience