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Fraud Investigator (QI Info Specialist)
Job#: 5633
Positions: 1
Posted: 07/03/2013
Job Type: Full Time
Location: Harrisburg, PA (BPI)
Department: PA Staffing
Category: Administrative Assistant
Salary: Hourly
Benefits: Full Benefits
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Job Description

Liberty Healthcare Corporation is accepting applications for a full-time Medicaid Fraud Investigator position which will serve the Commonwealth of Pennsylvania Department of Public Welfare (DPW) Office of Medical Assistance Programs, Bureau of Program Integrity.

The mission of the Bureau of Program Integrity is to ensure that:

  • the Medical Assistance Program is protected from provider fraud, abuse, and waste;
  • medical assistance recipients receive quality medical services;
  • medical assistance recipients do not abuse their use of medical services; and
  • feedback is provided to the Department to enhance program performance.

This Bureau is comprised primarily of medical professionals responsible for preventing, detecting, deterring, and correcting fraud, abuse, and wasteful practices by providers of medical assistance services, including managed care organizations, applying administrative sanctions, and referring cases of potential fraud to the appropriate enforcement agency. This responsibility includes evaluating services rendered by medical providers and managed care organization provider networks, monitoring recipient overuse and abuse, and maintaining ongoing working relationships with federal and state enforcement agencies involved in monitoring potential health care fraud and abuse.

The Bureau of Program Integrity’s office is located at 2301 N. Cameron Street in Harrisburg – across from the State Farm Show complex and on the grounds of the former Harrisburg State Hospital campus.

Learn more about the Bureau of Program Integrity online at http://www.dpw.state.pa.us/dpworganization/officeofadministration/bpi/index.htm

The Medicaid Fraud Investigator will work under the job title of Quality Improvement Information Specialist position and be responsible for the following duties:

 

  • Investigate medical claims data to identify fraud, waste, and abuse
  • Handle caseload of identified overpayments not requiring medical record review
  • Responsible for triage of Fraud and Abuse Referrals to the Bureau, including data investigation, documenting preliminary findings and transfer to appropriate Sections of the Bureau for further action.
  • Responsible for validating services through explanation of benefits responses received by the Bureau
  • Utilizes Business Objects software in the Fraud and Abuse Detection System (FADS) to create algorithms for the detection of fraud and abuse.
  • Creates proactive algorithms to identify new billing schemes for clinical staff review.
  • Supports Bureau Recovery projects by creating queries in FADS to extract data due to Bureau staff specifications.
  • Aid in identification and resolution of claims processing system defects
  • Reactive and Proactive Data Mining
  • Use multiple resources in the investigation process to identify potential incidents of fraud, waste, and abuse
  • Represent the Bureau in the resolution of any issues occurring with any of the job functions listed above
  • Travel to perform required duties as required.
  • Perform any other related duties as directed by the Section Supervisor

The incumbent will be hired as a full-time employee of Liberty Healthcare Corporation and work on a contractual basis through a successful partnership between Liberty and the Commonwealth of Pennsylvania.

As an employee of Liberty Healthcare the selected applicant will receive:

  • Annual compensation: $54,970.50  ( $28.19 / hour )
  • Benefits including both employer and employee sponsored individual / family health insurance, dental insurance, vision insurance, long-term disability insurance
  • 25 days of paid time off annually (includes holidays, vacation, personal and sick leave)
  • 401k plan

A detailed overview of Liberty Healthcare’s benefits may be found online at http://www.libertyhealthcare.com/upload/278.pdf

Skills/Requirements

To qualify, candidates must possess a Bachelors Degree and the following:

 

  • Basic Medical Claims Knowledge
  • Knowledge of CPT, HCPC, ICD-9 National Codes Sets a Plus
  • Familiar with Medical Terminology
  • PC knowledge in Windows environment
    • Microsoft Word
    • Microsoft Outlook
    • Microsoft Excel
    • Microsoft Access
    • Business Objects or SQL Knowledge a plus
  • Data Entry Skills
  • Mathematical Aptitude
  • Strong Organizational Skills
  • Ability to prioritize and manage workflow
  • Ability to meet deadlines and maintain Bureau quality standards
  • Attention to detail
  • Ability to get along well with others and work in a team environment
  • Maintains professional client relationships
  • Strong customer service skills
  • Excellent written and oral communication skills
  • Ability to quickly learn new concepts and apply them in work assignments
  • Data analysis or data warehousing knowledge is a plus
  • Fraud and Abuse experience a plus
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