Triage Investigator - Behavioral Health

Who We Are

Point32Health is a leading health and wellbeing organization, delivering an ever-better personalized health care experience to everyone in our communities. At Point32Health, we are building on the quality, nonprofit heritage of our founding organizations, Tufts Health Plan and Harvard Pilgrim Health Care, where we leverage our experience and expertise to help people find their version of healthier living through a broad range of health plans and tools that make navigating health and wellbeing easier.

We enjoy the important work we do every day in service to our members, partners, colleagues and communities.

Job Summary

Key Responsibilities/Duties - what you will be doing

• Developing a deep understanding of both health insurance claims operations and of fraudulent schemes that impact payors.
• Reviewing periodic claims queries / extracts to identify potentially fraudulent claim submissions or patterns.
• Performing background research on newly identified case leads, utilizing both internal records and online resources.
• Performing pre-payment review activity on flagged claims, including requesting records, seeking clinical review, and issuing letters back to submitting providers.
• Vetting referrals submitted through the plan's dedicated Fraud, Waste & Abuse hotline and e-mail box.
• Corresponding with various business units throughout the organization to understand various aspects of the health insurance reimbursement process including contract, payment, authorization and appeal divisions, among others.
• Seeking to enhance existing data-mining capabilities by partnering with management of the Analytics & Triage team to develop and refine queries to identify potential fraud, waste & abuse.
• Perform out-of-the-box thinking, collaborate with others, and make a difference every day!
• Other duties as assigned by the Director.

Qualifications - what you need to perform the job

QUALIFICATIONS:

• Bachelor's degree, preferably in a clinical or scientific field, business, computer science, or criminal justice.

• 3-5 years related experience in health insurance fraud investigations.

• Certified Professional Coder ("CPC"); Certified Fraud Examiner ("CFE") designation a plus.

• 3+ years related experience in audits/investigations (preferred).

SKILL REQUIREMENTS:

• Ability to produce clear, concise, and well-organized documents.

• Resilient, collaborative, flexible, innovative.

WORKING CONDITIONS AND ADDITIONAL REQUIREMENTS:

• Must be able to work under normal office conditions and work from home as required.

• May be required to attend meetings at other company locations or other external meetings.

• Work may require simultaneous use of a telephone/headset and PC/keyboard and sitting for extended durations.

• May be required to work additional hours beyond standard work schedule.

The above statements are intended to describe the general nature and level of work being performed by employees assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of employees assigned to this position. Management retains the discretion to add to or change the duties of the position at any time.

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Commitment to Diversity, Equity, Inclusion, Accessibility (DEIA) and Health Equity

Point32Health is committed to making diversity, equity, inclusion, accessibility and health equity part of everything we do-from product design to the workforce driving that innovation. Our Diversity, Equity, Inclusion, Accessibility (DEIA) and Health Equity team's strategy is deeply connected to our core values and will evolve as the changing nature of work shifts. Programming, events, and an inclusion infrastructure play a role in how we spread cultural awareness, train people leaders on engaging with their teams and provide parameters on how to recruit and retain talented and dynamic talent. We welcome all applicants and qualified individuals, who will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.