Over 35 years strong and fueled by 1,700 smart, passionate employees across New York state and Vermont, MVP is full of opportunities to grow. We are a nationally recognized, award-winning leader for a reason. The beating heart of our company is a wide range of employees from a diverse set of backgrounds—tech people, numbers people, even people people—working together to make health insurance better. If you are ready to join a thriving, mission-driven company where you can create your own opportunities and make a positive difference—it’s time to make a healthy career move to MVP!
This individual is responsible for investigating, reporting on and making recommendations on cases that have been identified as containing some element of fraudulent, wasteful and/or abusive activity. Ability to utilize various data management tools to help identify and/or research potential fraudulent, wasteful and abusive activity, including working knowledge of MS Office, Macess, Business Objects, Cognos, Facets, Care Radius, CMS websites, StarSentinel and iSight. Working knowledge of claim coding, such as CPT-4, HCPCS, ICD-9, and ICD-10 guidelines as they relate to claim data. Conduct on-site audits, including but not limited to audits of members' charts/records, members' accounts, and enrollment/eligibility. Organizes and conducts highly complex investigations, preparing informative written reports throughout the investigative process, in a timely and efficient manner, according to corporate and departmental SIU policies and procedures. Assists in investigations conducted by government agencies, including New York State Department of Insurance (Department of Financial Services), New York State Attorney General (Medicaid Fraud Unit), New York State Department of Health, US Attorney, Federal Bureau of Investigation, US Health and Human Services, CMS and other insurance company SIU staff. Submits reports of suspicious activity to federal and state agencies as required by statutory and regulatory requirements. Assists in creating provider education and corrective action plans. Provide information pertaining to investigations to the SIU Manager to be used as examples in annual SIU Fraud, Waste and Abuse corporate training. Testifies in criminal and civil legal proceedings as necessary. Stays current with Federal and State anti-fraud requirements, including HIPAA, CMS, Medicare, Medicaid and any corporate compliance initiatives or policies. May participate in meetings with providers, vendors, MVP employees and when appropriate, representatives from regulatory agencies. Develops and maintains a high degree of rapport and cooperation with federal, state and local law enforcement and regulatory agencies which can assist in investigative efforts. Keeps abreast of all current and upcoming legislation directives. Minimal travel may be required to obtain medical records pertaining to investigation and to conduct audits. Ability to maintain confidentiality and adhere to regulatory compliance issues as they exist and change from time to time; and Performs other related duties as assigned. POSITION QUALIFICATIONS...This is a remote position. Are you fascinated by the allure of the open seas and... ...We are seeking a dynamic Remote Cruise Consultant to join our team. As a Remote Cruise... ...candidates 18 years of age or older and legally authorized to work in the United States....
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