Responsible for the management of clinical reviews to assist in the prevention and detection of fraud, waste and abuse in all the Health Plan lines of business. Plan, organize, and execute medical reviews or audits that identify, evaluate and measure potential healthcare fraud and abuse.
Utilizes an expert knowledge of CPT, ICD-9, HCPCS coding and the Health Plan clinical and reimbursement policies to review and analyze claims and corresponding medical records for clinical medical record reviews.
Prepares concise clinical review summaries to support findings of potential fraud, waste and abuse Conducts in-depth research and makes recommendations to clarify coding and billing issues identified in fraud, waste and abuse cases.
Proactively identifies trends and schemes related to the potential inappropriate submission of claims.
Collaborates with Provider Network Management, Legal, Compliance, Payment Integrity and other departments to resolve potential fraud, waste and abuse issues identified during the audit process.
Provides guidance and services a resource for interpretation of provider billing practices to the FWA Unit.
Collaborates with Legal Department during case development, pursuit of recovery, presentation of findings and legal proceedings.
Provides case updates on progress of medical reviews to internal departments, committees and management.
Establishes and maintains quality relationships with public officials, law enforcement and others to obtain assistance in ongoing cases.
Reports potential issues identified that relate to the the Health Plan Fraud and Abuse policy.
Conducts onsite provider audits and provides member and provider and employee education related to clinical review findings.
Required yearly CEU education to maintain coding certification.
Work is typically performed in an office environment. Accountable for satisfying all job specific obligations and complying with all organization policies and procedures. The specific statements in this profile are not intended to be all-inclusive. They represent typical elements considered necessary to successfully perform the job.
Bachelor's Degree- (Required)
Minimum of 3 years-Related work experience (Required)
Certification(s) and License(s)
Certified Professional Coder - American Academy of Professional Coders (AAPC)
OUR PURPOSE & VALUES: Everything we do is about caring for our patients, our members, our students, our Geisinger family and our communities. KINDNESS: We strive to treat everyone as we would hope to be treated ourselves. EXCELLENCE: We treasure colleagues who humbly strive for excellence. LEARNING: We share our knowledge with the best and brightest to better prepare the caregivers for tomorrow. INNOVATION: We constantly seek new and better ways to care for our patients, our members, our community, and the nation. SAFETY: We provide a safe environment for our patients and members and the Geisinger family We offer healthcare benefits for full time and part time positions from day one, including vision, dental and domestic partners.* Perhaps just as important, from senior management on down, we encourage an atmosphere of collaboration, cooperation and collegiality. We are an Affirmative Action, Equal Opportunity Employer Women and Minorities are Encouraged to Apply. All qualified applicants will receive consideration for employment and will not be discriminated against on the basis of disability or their protected veteran status.
We are an Affirmative Action, Equal Opportunity Employer Women and Minorities are Encouraged to Apply. All qualified applicants will receive consideration for employment and will not be discriminated against on the basis of disability or their protected veteran status.
At Geisinger, our innovative ideas are inspired by the communities we serve – like our Fresh FoodFarmacy, a program that delivers life-saving healthy alternatives to patients with diabetes. With additional tools like our MyCode Community Health Initiative, one of the first health system genome sequencingprograms, and our new asthma app suite that we developed in partnership with AstraZeneca, it’s no wonder we’re ranked one of the Top 5 Most Innovative Healthcare Systems by Becker's Hospital Review. We continually work towards continuous improvement in a culture where everyone has a voice and firmly believe that better begins with all of us.Founded more than 100 years ago, Geisinger serves more than three million residents throughout central, south-central and northeastern Pennsylvania and southern New Jersey. Our physician-led system is comprised of 30,000 employees, including 1,600 employed physicians, and consists of 13... hospital campuses, the Geisinger Health Plan, Geisinger Commonwealth School of Medicine and two research centers. What you do at Geisinger shapes the future of health and improves lives – for our patients, communities, and you.