Company Description |
VNS CHOICE is a comprehensive, managed long-term care program for adults 65 and older who wish to remain in their own homes with long term care services for as long as possible. We are seeking talent for the opportunity described below.
Performs desk and on-site medical record audits in possible cases of insurance fraud, assists in assembling evidence, and recommends action steps. Develops a broad presence in the company and availability to assist operational areas with questions about cases of possible fraud. Prepares timely and complete investigations and cases based upon analysis of allegations and information from internal and external sources. Exercises due diligence to prevent, detect, and report unlawful and/or unethical conduct by fellow co-workers, professional affiliates, and/or agents. Evaluates and analyzes Medicare and Medicaid records, researches monetary losses, conducts independent investigations and contributes to improved healthcare delivery by identifying and eliminating fraud, waste and abuse. Works under general supervision.
Education: Bachelors degree in accounting, law enforcement, criminal justice, nursing or other healthcare field required. Experience: Advanced knowledge of E/M documentation guidelines, other best practices in medical record documentation, CPT-4, HCPCS level II and III, ICD-9-CM and the intricacies of tying coding and documentation together are critical. Minimum of three years of coding experience involving detecting and investigating fraud, developing fraud cases, reviewing claims and performing medical review within the Medicare program required. CFE (Certified Fraud Examiners) designation preferred. Very strong knowledge of Medicare, Medicaid statues, regulations, policies, claim processing, audit and reimbursement principles and procedures required. Excellent investigative, communication and organizational skills required. Knowledge of HIPAA Privacy and Security Rules and CMS security requirements preferred.
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