NAELA's CareerCenter

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Job Purpose
This is a senior-level technical position in the Special Investigation Unit (SIU) intended to perform in-depth complex clinical medical record reviews of pre-payment and post-payment claims across FEP (Federal Employee Program) and other lines of business related to case investigations. This position requires the ability to analyze medical review findings and claims data to identify and report on trending of potential fraud, waste and abuse (FWA) activity against all Florida Blue lines of business. This role requires clinical and coding certifications to independently perform medical record reviews from a clinical, medical coding and provider billing perspective to identify potential FWA. This role requires documentation of medical record review findings, which may be used in case investigations for referrals to multiple law enforcement and regulatory agencies. This role is also responsible for assisting with the consultation related to investigative activities within the SIU, independently performing onsite provider audits, accompanying investigators as needed with field investigations, interacting directly with providers and their attorneys, and testifying in court as an expert witness.

What You Will be Doing:

• Leverages clinical and coding expertise to independently perform assigned complex clinical medical record reviews of pre-payment and post-payment claims across all lines of business related to case investigations involving potential FWA. Identifies and documents all inappropriate and non-compliance with Florida Blue policies and procedures, government contracts, State and Federal guidelines and coding and billing industry standards.
• Communicates clinical medical record review findings in writing to investigators, senior leadership, legal, providers, members, outside counsel, law enforcement & regulatory agencies. Thorough documentation of medical record review findings in summaries, letters & presentations. This position may require participation in onsite meetings, workgroups & collaborative sessions.
• Analyzes claims data and medical review findings to identify and report on aberrant patterns and trending of potential fraud, waste and abuse (FWA) activity related to all lines of business, with a focus on FEP.
• Conducts independent clinical medical record reviews at provider offices/facilities as needed.
• Assist with the coordination and collaboration of investigative activities within the SIU.
• Assist with quality reviews and the coordination of work performed by vendors.
• Assist with training new staff.
• Developing and conducting presentations for internal and external business partners, FWA organizations and law enforcement.
• Identify Medical Cost Savings and Continuous Improvement opportunities through the use of medical record review findings.
• May serve as lead or SME on various internal/departmental projects and workgroups.
• The essential functions listed represent the major duties of this role, additional duties may be assigned.

What You Must Have:
3+ years related work experience to include prior medical review experience with a focus on investigations, compliance,  fraud, waste and abuse, or FEP medical review experience.

High school diploma or GED

RN - Registered Nurse - Florida State Licensure And/Or Compact State Licensure Active RN license
Medical Coding Certification (CPC, COC, CCS, or CCS-P)

Working knowledge in Word, Excel, PowerPoint Excellent verbal and written communication, coordination, analytical, and problem-solving skills Working knowledge of various lines of business (FEP, State, Medicare C/D, Commercial) Working knowledge of COB/OPL, Subrogation and Workers' Comp, standard claims adjustment processes and benefit plans Demonstrate flexibility in unplanned work and/or project support Nursing and medical record review coding determination

What We Would Prefer You Have:
Bachelor’s degree
Master’s degree
Prior experience with FEP (Federal Employee Program)

Healthcare fraud audit/investigation experience

Presentation skills experience

Strong analytics experience

Compliance experience.

General Physical Demands
Sedentary work: Exerting up to 10 pounds of force occasionally to move objects. Jobs are sedentary if traversing activities are required only occasionally.

Physical/Environmental Activities
Must be able to travel to multiple locations for work (i.e. travel to attend meetings, events, conferences). Occasionally

We are an Equal Opportunity/Protected Veteran/Disabled Employer committed to creating a diverse, inclusive and equitable culture for our employees and communities.