Mutual of Omaha · 8 hours ago

Medicare Payment Integrity Investigator -Remote

United States

Full-time

Remote

Senior Level

$60K/yr - $75K/yr

7+ years exp

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Responsibilities

Performs review of healthcare claims to substantiate or refute the accuracy and compliance with federal and state regulations and contractual requirements of codes billed to identify coding errors and billing discrepancies in relation to incidents of suspected healthcare fraud, waste, and abuse (FWA).

Act as a liaison with 3rd party vendors, including identifying data trends, validating rules, making recommendations for improvement, and providing updates to management.

Proactively seeks out and develops leads from a variety of sources (e.g., CMS, OIG, HFPP, NHCAA)

Perform evaluation of leads, complaints, and/or investigations. Conduct independent reviews resulting from the discovery of situations that potentially involve FWA, including communicating with medical providers and policyholders.

Develop appropriate recommendations and suggestions based on analysis and collaborate with management in the development of action plans where required.

Qualification

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Medicare claims managementInvestigative experienceMedical codingHealthcare regulationsData trend analysisThird-party vendor collaborationICD codingCPT codingHCPCS codingDRG codingRevenue codesNDC guidelinesLead developmentCertified Professional Coder

Required

Seven+ years of advanced Medicare claims management and/or investigative experience.

Prior experience performing comprehensive reviews of Medicare healthcare claims to ensure accuracy, compliance with federal and state regulations, and alignment with contractual requirements.

Experience working with third-party vendors to identify data trends, validate coding rules, and recommend improvements that drive better outcomes.

Experience identifying and developing leads from trusted sources like CMS, OIG, HFPP, and NHCAA, evaluating them to uncover potential FWA cases.

In-depth knowledge of medical coding, billing practices, and healthcare regulations. In-depth understanding of ICD, CPT, HCPCS, DRG, revenue codes, NDC’s and other guidelines and general understanding of investigative processes within a healthcare environment are required.

You promote a culture of diversity and inclusion, value different ideas and opinions, and listen courageously, remaining curious in all that you do.

Able to work remotely with access to a high-speed internet connection and located in the United States or Puerto Rico.