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Cotiviti · 11 hours ago

Senior Investigator (Healthcare FWA) Provider Escalations

United States

Full-time

Remote

Mid, Senior Level

$70K/yr - $90K/yr

5+ years exp

Cotiviti is a company focused on healthcare analytics and fraud prevention. As a Senior Investigator, you will investigate suspected incidents of healthcare fraud, waste, or abuse, primarily supporting provider escalations related to prepayment FWA services.

Information Technology & Services

Hiring Manager

Judy Brower

Responsibilities

Act as the primary contact for escalated provider-related concerns related to Cotiviti’s prepayment FWA service, ensuring timely and thorough resolution

Educate providers regarding Cotiviti claim determinations including review of coding and payment guidelines, plan policy, and other relevant sources

Partner with Cotiviti clients and internal client services staff to resolve provider complaints, schedule educational calls, disseminate relevant reporting and recommend subsequent investigative steps

Document and report detailed records of escalations, investigations, and outcomes. Prepare reports for internal and external use

Identify, investigate, analyze and evaluate instances of potential fraud, waste, and abuse

Conduct interviews or correspond with patients, providers, witnesses or other relevant parties to determine settlement, denial or review

Analyze information gathered by investigation and report findings and recommendations as a written summary and/or presentation

Conducts investigation-related training

Supports legal proceedings as needed, including testifying in court or working with law enforcement personnel to prepare cases for civil or criminal actions

Negotiates settlement agreements to resolve disputes

Maintain current knowledge of relevant laws, regulations and standards

Participates in special projects as required

Qualification

ExcelData miningData extrapolationCPC certificationFWA toolsListening skillsPrioritization skillsCommunication skillsAttention to detailOrganizational skills

Required

Bachelor's Degree in related discipline, or the equivalent combination of education, professional training and work experience

5-8 years of related investigative experience

Experience in proactive data mining

Experience in sampling and data extrapolation; prior use with RAT-STATS preferred

Advanced level skills in Excel

Excellent verbal and written communication skills

Strong listening and observation skills

Attention to detail and high level of accuracy

Effective organizational and prioritization skills with multi-tasking ability

Required certifications: Certified Professional Coder (CPC)

Preferred

Experience with Cotiviti's FWA tools (preferred) - Sentinel, Commander, and/or Informant (Stars Solutions)

Preferred certifications: Accredited Healthcare Fraud Investigator (AHFI), Certified Fraud Specialist (CFS), Certified Fraud Examiner (CFE), Certified Forensic Interviewer (CFI), or Certified in Healthcare Compliance (CHC)

Benefits

Medical

Dental

Vision

Disability

Life insurance coverage

401(k) savings plans

Paid family leave

9 paid holidays per year

17-27 days of Paid Time Off (PTO) per year, depending on specific level and length of service with Cotiviti

Company

Cotiviti

Glassdoor3.7

Cotiviti enables healthcare organizations to deliver better care at lower cost through advanced technology and data analytics that improve the quality and sustainability of healthcare in the United States.

Founded in 1979

South Jordan, UT, US

5001-10000 employees