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UPMC · 1 day ago

SIU Investigator - Remote

United States

Full-time

Remote

Entry, Mid Level

2+ years exp

UPMC Health Plan is seeking a SIU Investigator for their Special Investigations Unit. The role involves investigating dental fraud, waste, and abuse cases, analyzing claims data, and maintaining detailed records of investigative activities.

BiotechnologyHealth CareHospitalMedical

Responsibilities

Investigative actions include member/provider outreach, financial tracking, adhering to compliance regulations, and making healthcare oversight referrals

Plan, organize and execute dental investigations or dental audits utilizing document review, witness interviews, and data analysis to identify, evaluate and measure potential healthcare fraud, waste and abuse to determine valid cases for appropriate action

Risk Assessments on FWA dental trends using fraud detection software and/or as assigned by Manager

Present FWA training to internal staff

Perform dental chart reviews to assess compliance with dental coding and billing regulations

Utilize standard coding guidelines, principles, and coding clinics to monitor the appropriate ICD-10, CDT and CPT codes for all record types to ensure accurate reimbursement

Document and track activity in an internal database, provide case updates on the progress of the dental audit and dental investigation and coordinate with management recommendations and further actions and/or resolutions

Conduct detailed research to identify and apply appropriate regulatory, contractual, and industry requirements to the different dental benefits and products within investigations

Maintain or exceed designated quality and production goals. Understand and adhere to HIPAA privacy requirements. Perform special projects assigned by Management

Qualification

Dental investigationsClaims data analysisCPTICD-10 codingHealthcare fraud detectionMedical terminologyMS Office proficiencyProblem solvingOrganizational skillsOral communicationWritten communication

Required

Bachelor's Degree preferred or 2-4 years of related experience in investigations, claims, medical coding, auditing, compliance, risk management and/or data analysis required

The ability to problem solve and communicate professionally

Detail oriented individual with excellent organizational skills

High degree of oral and written communication skills

Proficiency in MS Office/PC skills including Microsoft Excel and Word