Job Description

SIU Program Integrity Investigator - Remote in Idaho at Magellan Health Services in Boise, Idaho, United States Job Description Responsible for conducting compliance audits, risk assessments, investigations, education and training assignments relating to billing, coding, reimbursement and documentations. At least sixty percent of the time involves working in the field with vendors, subcontractors and providers. Responsible for conducting claims and compliance audits for the purpose of detecting and/or recovering inappropriate benefit payments due to billing inaccuracies and/or abusive and fraudulent practices, as well as complying with state and federal regulatory compliance and fraud reporting requirements. + Conducts reviews of behavioral health consumers' medical record to assess whether covered behavioral health services delivered to the consumer and billed to Medicaid are accurate and appropriate. + Prepares detailed audit findings reports. + Tracks and trends compliance statistics and use to implement strategies to improve provider compliance. + Implements corrective action as necessary to ensure the highest levels of provider compliance. + Conducts re-audits of providers' medical records to verify corrective actions were fully implemented and effective. + Collaborates and work in coordination with other subject matter experts in Special Investigations Unit (SIU), cost containment, legal, claims, network, compliance and external county and federal and state regulatory authorities such as the Bureau of Program Integrity, Department of Public Welfare, Office of the Attorney General and others to identify, investigate and report overpayment, duplicative payment, false claims, abuse, and fraud situations and, as appropriate, assist in the process of recovery of overpayments. + Reviews and monitors provider compliance with Medicaid Licensing and billing requirements in all levels of Medical Assistance funded care. + Conducts provider and member interviews as a part of the overall review process. + Ensures providers have a compliance plan and policies and procedures that detail provider expectations. + Reviews, monitors and reports on providers' effective implementation of the plan. + Further develops comprehensive audit and monitoring tools, provider compliance plan expectations, provider training materials and reporting templates etc. + Provides technical assistance as needed. + Presents findings reports at designated meetings (i.e. internal, customer, provider, etc.) + Ensures compliance regarding HIPAA regulations and forward mandatory reports to designated recipients. Other compliance related duties as instructed. Other Job Requirements Responsibilities Bachelor's degree and 2+ years' experience or 6+ years' experience without the degree. Knowledge of Medicaid licensing and billing requirements, DSM-IV. Ability to collaborate with many functional areas of a national organization. Large and, at times, complex database management skills coupled with strong working knowledge of Excel. Knowledge of HIPAA. Healthcare experience. General Job Information Title SIU Program Integrity Investigator - Remote in Idaho Grade 22 Work Experience - Required Healthcare Work Experience - Preferred Education - Required A Combination of Education and Work Experience May Be Considered., Bachelor's Education - Preferred Master's License and Certifications - Required License and Certifications - Preferred Salary Range Salary Minimum: $50,225 Salary Maximum: $75,335 This information reflects the anticipated base salary range for this position based on current national data. Minimums and maximums may vary based on location. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law. This position may be eligible for short-term incentives as well as a comprehensive benefits package. Magellan offers a broad range of health, life, voluntary and other benefits and perks that enhance your physical, mental, emotional and financial wellbeing. Magellan Health, Inc. is proud to be an Equal Opportunity Employer and a Tobacco-free workplace. EOE/M/F/Vet/Disabled.Every employee must understand, comply with and attest to the security responsibilities and security controls unique to their position; and comply with all applicable legal, regulatory, and contractual requirements and internal policies and procedures. Magellan is the employer of choice for hard working people interested in making a difference in the health care industry and in the communities where we work and live. Our strong culture of caring is the common thread in both our business strategy and our work environment. We value professional growth and development, total health and wellness, rewards and recognition as well as employee unity. Magellan is a place where you can thrive. Magellan is committed to providing equal employment opportunities to employees and applicants for employment without regard to race, color, creed, religion, sex, gender identity and expression, sexual orientation, marital status, age, national origin, ancestry, citizenship, physical or mental disability, disabled veteran or veteran of the Vietnam Era status, or any other factors protected by law. Magellan is committed to meeting applicable Federal labor and employment law posting requirements by providing necessary posters in a format which is easily accessible and conspicuous to all applicants. Copies of applicable posters are accessible by clicking here (. Warning: Employment Scam It has come to our attention that a false representative is contacting potential candidates and offering them work at home positions with Magellan Health. 'Interviews' are conducted completely through email and the false job offer includes the promise of a check to be issued to the candidate for the purposes of setting up a home office. Please know that Magellan Health does not interview any candidate through email, nor do we issue checks to candidates to set up home offices. All of our available positions are posted on legitimate job boards and our recruitment team directly contacts candidates should there be a fit. If you suspect you are being contacted by a false representative of Magellan Health, please call 410-953-2911 To view full details and how to apply, please login or create a Job Seeker account

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