Nurse Investigator
HealthNow New York Inc. - Buffalo, NY

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Position Summary: Under the direction of management, this position is responsible for identifying potential/actual fraud/abuse through comprehensive medical record and claims review of all HealthNow contracted providers. Concomitant responsibilities include initiation and completion of provider audits, post-audit provider education and evaluation to ensure corporate and regulatory compliance. Integral to the role is communication of identified audit issues to contracted providers, health care regulators, legal counsel and other internal and external stakeholders.

Primary Job Duties:
  • Thorough review of voluminous, complex medical records to determine: a) correct usage of CPT-4 and ICD-9 coding, b) documentation substantiates the level of service billed, c) patient quality of care issues d) services not rendered, churning of physician office visits, e) all the critical elements of the medical documentation are present in the patient record. As a result of the findings of these reviews, interaction with hospital representatives at all levels to facilitate record reviews and discussion of review findings will be necessary
  • Organize and prioritize multiple cases concurrently to ensure departmental workflow and case resolution
  • Meetings with physicians, medical facility representatives and often, their legal counsel, to discuss complex issues identified in the audit
  • Meeting with BCBS medical directors and physician consultants to review audit issues
  • Maintain close communication with colleagues in Utilization Management, Network Management and other departments as needed to ensure consistency of information
  • Assist in the research and follow-up of complex fraud hotline call resolution, including explaining issues to members and providers
Required Skills Primary Skills/Knowledge:
  • Extensive knowledge of current, complex medical issues including emerging technology is essential; as well as knowledge of coding classifications including ICD - 9CM, CPT4, HCPCS, E/M level coding, DRG/APC grouping schemes, reimbursement regulations and revenue cycle functions, and NYS reporting requirements
  • Basic proficiency in MS Word, Excel, Lotus Notes and Internet
  • Excellent time management skills
  • Excellent organizational skills and attention to detail
  • Excellent verbal and written communication skills
  • Ability to work effectively with minor supervision
  • Must be able to work in a fast-paced environment with daily work processing deadlines
  • High degree of business maturity and demonstrated confidentiality
  • High energy level and ability to project enthusiasm
  • Persuasive communication style
  • Polished, professional image and reputation
  • Demonstrated personal accountability
  • Valid drivers license and acceptable driving history required due to travel involved with this position (DMV check will be conducted to review candidate's driving record)
Required Experience Preferred Education:
  • Associates Degree in health care related field required
Preferred Experience:
  • 1-2 years work experience in a similar function required
Required Licenses/Certifications:
  • Registered Nurse
  • Certified Professional Coder