SIU Investigator at Prominence Health Reno, NV

Summary

SIU Investigator job at Prominence Health. Reno, NV.Responsibilities Prominence Health is a value‑based care organization bridging the gap between affiliated health systems and independent providers, building trust and collaboration between the two. Prominence Health creates value for populations and providers to strengthen integrated partnership, advance market opportunities, and improve outcomes for our patients and members. Founded in 1993, Prominence Health started as a health maintenance organization (HMO) and was acquired by a subsidiary of Universal Health Services, Inc. (UHS) in 2014. Prominence Health serves members, physicians, and health systems across Medicare, Medicare Advantage, Accountable Care Organizations, and commercial payer partnerships. Prominence Health is committed to transforming healthcare delivery by improving health outcomes while controlling costs and enhancing the patient experience.Job Summary The Special Investigations Unit is responsible for investigating and resolving high‑complexity healthcare fraud, waste and abuse (FWA) by medical professionals, facilities, and members. This position researches, gathers, and analyzes claims data, medical records, corporate policy, state/federal policy, and practice standards to identify trends, patterns, aberrancies, and outliers in provider billing behavior. Serves as a subject matter expert for other investigators. Responsible for conducting compliance audits, risk assessments, investigations, and education related to billing, coding, reimbursement, and documentation. This position is full‑time.Benefit Highlights Loan Forgiveness ProgramChallenging and rewarding work environmentCompetitive Compensation & Generous Paid Time OffExcellent Medical, Dental, Vision and Prescription Drug Plans401(K) with company match and discounted stock planSoFi Student Loan Refinancing ProgramCareer development opportunities within UHS and its 300+ Subsidiaries. More information is available on our Benefits Guest Website: benefits.uhsguest.comQualifications Bachelor's Degree or equivalent years of relevant work experience in a Health‑Related Field or Insurance requiredLicenses/Certifications: Coding certification from an accredited organization (American Academy of Professional Coders or American Health Information Management Association) OR RN, LPC, LCSW, LMHC2+ years of medical coding experience OR RN, LPC, LCSW, LMHC, PT, OT or ST license and 2+ years of related clinical experience in the field of the obtained licenseExperience in healthcare fraud investigations, auditing, data analytics or related fieldPreferred certifications: Accredited Healthcare Fraud Investigator (AHFI), Certified Fraud Examiner (CFE), and Certified Professional Coder (CPC)Ability to perform intermediate data analysis and to articulate understanding of findingsAbility to work under limited supervision with moderate latitude for initiative and independent judgmentAbility to manage demanding investigative case loadStrong written skills with ability to compose detailed investigative reports and professional internal and external correspondencesIntermediate proficiency level in Microsoft OfficeEffective listening and critical thinking skills and the ability to identify gapsStrong interpersonal skills, high level of professionalism, integrity and ethics in performance of all dutiesExcellent problem solving and decision‑making skills with attention to detailsEEO Statement All UHS subsidiaries are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates. UHS subsidiaries are equal opportunity employers and as such, openly support and fully commit to recruitment, selection, placement, promotion and compensation of individuals without regard to race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status or any other characteristic protected by federal, state or local laws. We believe that diversity and inclusion among our teammates is critical to our success.#J-18808-Ljbffr

Job Description

SIU Investigator job at Prominence Health. Reno, NV.Responsibilities Prominence Health is a value‑based care organization bridging the gap between affiliated health systems and independent providers, building trust and collaboration between the two. Prominence Health creates value for populations and providers to strengthen integrated partnership, advance market opportunities, and improve outcomes for our patients and members. Founded in 1993, Prominence Health started as a health maintenance organization (HMO) and was acquired by a subsidiary of Universal Health Services, Inc. (UHS) in 2014. Prominence Health serves members, physicians, and health systems across Medicare, Medicare Advantage, Accountable Care Organizations, and commercial payer partnerships. Prominence Health is committed to transforming healthcare delivery by improving health outcomes while controlling costs and enhancing the patient experience.Job Summary The Special Investigations Unit is responsible for investigating and resolving high‑complexity healthcare fraud, waste and abuse (FWA) by medical professionals, facilities, and members. This position researches, gathers, and analyzes claims data, medical records, corporate policy, state/federal policy, and practice standards to identify trends, patterns, aberrancies, and outliers in provider billing behavior. Serves as a subject matter expert for other investigators. Responsible for conducting compliance audits, risk assessments, investigations, and education related to billing, coding, reimbursement, and documentation. This position is full‑time.Benefit Highlights Loan Forgiveness ProgramChallenging and rewarding work environmentCompetitive Compensation & Generous Paid Time OffExcellent Medical, Dental, Vision and Prescription Drug Plans401(K) with company match and discounted stock planSoFi Student Loan Refinancing ProgramCareer development opportunities within UHS and its 300+ Subsidiaries. More information is available on our Benefits Guest Website: benefits.uhsguest.comQualifications Bachelor's Degree or equivalent years of relevant work experience in a Health‑Related Field or Insurance requiredLicenses/Certifications: Coding certification from an accredited organization (American Academy of Professional Coders or American Health Information Management Association) OR RN, LPC, LCSW, LMHC2+ years of medical coding experience OR RN, LPC, LCSW, LMHC, PT, OT or ST license and 2+ years of related clinical experience in the field of the obtained licenseExperience in healthcare fraud investigations, auditing, data analytics or related fieldPreferred certifications: Accredited Healthcare Fraud Investigator (AHFI), Certified Fraud Examiner (CFE), and Certified Professional Coder (CPC)Ability to perform intermediate data analysis and to articulate understanding of findingsAbility to work under limited supervision with moderate latitude for initiative and independent judgmentAbility to manage demanding investigative case loadStrong written skills with ability to compose detailed investigative reports and professional internal and external correspondencesIntermediate proficiency level in Microsoft OfficeEffective listening and critical thinking skills and the ability to identify gapsStrong interpersonal skills, high level of professionalism, integrity and ethics in performance of all dutiesExcellent problem solving and decision‑making skills with attention to detailsEEO Statement All UHS subsidiaries are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates. UHS subsidiaries are equal opportunity employers and as such, openly support and fully commit to recruitment, selection, placement, promotion and compensation of individuals without regard to race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status or any other characteristic protected by federal, state or local laws. We believe that diversity and inclusion among our teammates is critical to our success.#J-18808-Ljbffr