Closing: Apr 5, 2024
This position has expiredPublished: Mar 27, 2024 (31 days ago)
Job Requirements
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Job Summary
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- Bachelor's Degree in Medicine, Nursing, or related disciplines
- Knowledge of healthcare operations, fraud prevention, and regulatory compliance.
- Experience in conducting fraud, waste, and abuse investigations is preferred.
- Knowledge of emergency management protocols and procedures.
- Familiarity with mortality review processes and quality improvement initiatives.
- Knowledge of legal and regulatory requirements related to fraud, waste, and abuse investigations, emergency care, and case management.
- Professional certifications in fraud examination, case management, or related fields (e.g., Certified Fraud Examiner, Certified Case Manager) are advantageous.
Responsibilities
- Bachelor's Degree in Medicine, Nursing, or related disciplines
- Knowledge of healthcare operations, fraud prevention, and regulatory compliance.
- Experience in conducting fraud, waste, and abuse investigations is preferred.
- Knowledge of emergency management protocols and procedures.
- Familiarity with mortality review processes and quality improvement initiatives.
- Knowledge of legal and regulatory requirements related to fraud, waste, and abuse investigations, emergency care, and case management.
- Professional certifications in fraud examination, case management, or related fields (e.g., Certified Fraud Examiner, Certified Case Manager) are advantageous.
- Analyze claims data, billing records, and other relevant information to identify patterns, anomalies, and potential cases of fraud, waste, and abuse
- Utilize data analytics tools and techniques to identify trends, outliers, and potentially fraudulent activities
- Manage the escalation of emergency cases, ensuring timely and appropriate interventions for enrollees in critical or life-threatening situations
- Collaborate with healthcare providers, emergency services, and internal teams to coordinate and facilitate emergency care and support
- Conduct investigations into cases involving the mortality of enrollees to determine the cause, identify potential gaps in care, and assess the quality of care provided
- Collaborate with medical professionals, forensic experts, and internal teams to gather relevant information and conduct thorough investigations
- Monitor ICU admissions of enrollees, ensuring appropriate utilization and timely interventions, assessing the necessity and appropriateness of continued stay in the ICU
- Maintain accurate documentation of emergency cases, including communication, actions taken, and outcome
- Ensure compliance with applicable laws, regulations, and company policies related to fraud, waste, and abuse investigations, emergency case management, mortality investigations, general case management, managing at-risk cases, and ICU admissions
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