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MVP Health Care · 4 months ago

Clinical Investigator

United States

Full-time

Remote

Mid, Senior Level

$69K/yr - $80K/yr

5+ years exp

MVP Health Care is on a mission to create a healthier future for everyone, and they are seeking a Clinical Investigator to join their team. The role involves conducting clinical reviews, organizing complex investigations, and ensuring compliance with ethical standards while interacting with various corporate personnel.

Health CareHealth InsuranceInsuranceMedicalNon Profit

H1B Sponsor Likely

Responsibilities

Conduct clinical reviews of various forms of medical documentation and records obtained from providers and facilities including but not limited to medical charts, patient account records, and member interviews

Organize and conduct highly complex investigations. Document findings and recommendations throughout the investigative process in a timely and efficient manner according to corporate and departmental SIU policies and procedures

Act as an SIU liaison and interact with and analyze data in cooperation with Pharmacy, Medical Affairs, Operations, Provider Relations, Credentialing, Customer Care Center, Legal and other corporate personnel

Assist in investigations conducted by government agencies, law enforcement, and other insurance company SIU staff

Make recommendations for and conduct clinical re-audits of providers and facilities previously audited by SIU

Testify in criminal and civil legal case proceedings as necessary and assist outside legal counsel especially concerning issues needing clinical decision making

Participate in annual Corporate FWA training and training of new SIU personnel

Keep abreast of Federal and State Anti-Fraud investigation and reporting requirements including HIPAA, CMS, Medicare, Medicaid, and any corporate compliance initiatives or policies

Minimal travel may be required pertaining to investigations and audits

Contribute to our humble pursuit of excellence by performing various responsibilities that may arise, reflecting our collective goal of enhancing healthcare delivery and being the difference for the customer

Qualification

Insurance claims investigationLicensed medical professionalNew York State Nursing licenseCPC credentialCPT-4 coding knowledgeICD-10-CM coding knowledgeData management toolsAnalytical skillsMS Office proficiencyCuriosityHumilityVerbal communicationWritten communicationOrganizational skillsTeam collaboration

Required

BA/BS degree in criminal justice or a related field, and minimum of five years of insurance claims investigation experience; or five years of professional investigation experience with law enforcement agencies, or seven years of professional investigation experience involving economic or insurance related matters

A duly licensed or authorized medical professional, including but not limited to MD or RN

New York State Nursing license required (RN preferred)

Experience in health insurance fraud investigations preferred

Obtain CPC and/or COC credential

Maintain nursing license and coding credentials through continuing education process as required

Superior judgment skills, verbal and written communication, and presentation skills

Extremely detail-oriented with excellent organizational and analytical skills

Ability to utilize various data management tools to help identify potentially fraudulent activity

Possess knowledge of CPT-4, ICD-9-CM, ICD-10-CM, HCPCS and CPT Assistant coding guidelines as they relate to claim data

Working knowledge of MS Office (Word, Excel and Outlook)

Curiosity to foster innovation and pave the way for growth

Humility to play as a team

Commitment to being the difference for our customers in every interaction

Preferred

Working knowledge of Macess, Facets, CareRadius, Cognos, CMS web sites, and Encoder-Pro

Benefits

Growth opportunities to uplevel your career

A people-centric culture embracing and celebrating diverse perspectives, backgrounds, and experiences within our team

Competitive compensation and comprehensive benefits focused on well-being

An opportunity to shape the future of health care by joining a team recognized as a Best Place to Work For in the NY Capital District, one of the Best Companies to Work For in New York, and an Inclusive Workplace.

Company

MVP Health Care

Glassdoor3.3

MVP Health Care is a health care insurance provider for individuals, families, and companies.

Founded in 1982

Schenectady, New York, USA

1001-5000 employees

https://www.mvphealthcare.com

H1B Sponsorship

MVP Health Care has a track record of offering H1B sponsorships. Please note that this does not guarantee sponsorship for this specific role. Below presents additional info for your reference. (Data Powered by US Department of Labor)

Distribution of Different Job Fields Receiving Sponsorship

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Trends of Total Sponsorships

2024 (1)