Fraud Investigator
HealthSpring - Nashville, TN

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Part of the Benefit Integrity Unit (BIU). Serves a key role in investigating inappropriate billing practices, including fraud and abuse and other forms of provider and member misrepresentations. Investigations involve extensive internal and external research and detailed analysis. Ensures compliance with all requirements related to BIU and fraud, waste and abuse investigations.

Required Skills

Audits the Plan’s providers and members to identify fraudulent and abusive billing practices as well as member misrepresentation related to eligibility, identity or abuse of benefits; prepares investigative findings for internal recovery efforts or for referral to state and federal enforcement agencies; works cooperatively with other Plan departments including Provider Relations, Claims, Finance and Internal Audit; interfaces with providers, provider representatives and where appropriate, representatives from regulatory agencies; updates appropriate staff regularly on progress of investigations and makes recommendations for further initiatives or closing the case.

Required Experience

Minimum Requirements: Bachelor’s Degree in Business, Clinical, or related field; working knowledge of medical terminology and experience reviewing medical records; strong oral and written communications skills; minimum three years of related experience as an investigator with exposure to the healthcare industry; claims-related experience including strong working knowledge of coding, fee and reimbursement and claims processing policies and procedures.

Preferred Requirements: Clinical expertise; Previous state/federal regulatory, Medicare Advantage health plan or Prescription Drug health plan compliance/investigation experience.

HealthSpring, Inc. is an EEO/AA employer.

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Looking to keep a spring in Grandma's step, HealthSpring provides Medicare Advantage plans and Medicare Part D prescription drug...