Investigator - Regulatory Compliance Analyst - Lumen Solutions Group, Inc.

Job Title: Investigator - Regulatory Compliance Analyst

Job Description:

The role of the Special Investigations Unit (SIU) Investigator is to assist in the reduction and recuperation of losses through the detection, investigation, and resolution of low to medium levels fraud, waste, and abuse schemes, resulting in the savings and recovery of funds.

Responsibilities:

Independently conduct low to medium level investigations and provide support as part of an assigned team to all levels (low to medium) investigations of suspected fraud, waste, and abuse. In conjunction with assigned team or management, develop and execute investigative plans that may include performance of audits of financial business records, provider and subscriber medical data, claims, systems’ reports, medical records, analysis of contract documents, provider/subscriber claims history, benefits, external data banks and other documents to determine the possible existence of fraud and/or abuse. Provide support for offsite audits/investigations and interviews when requested. Research provider/subscriber claims activity, operations manuals, data systems, medical policies, job duties and group benefit contracts to identify control deficiencies and non-compliance. Investigator will develop documentation to substantiate finding including formal reports, spreadsheets, graphs, audit logs, use of anti-fraud software and appropriately sourced reference materials. Must ensure audits and investigations are timely, effective and result in an overall achievement of unit goals.

Investigator researches and analyzes claims data using company anti-fraud software, Excel, and other tools to proactively identify new potential cases. Investigator will develop documentation that supports conclusions, recommendations, and substantiates findings including formal correspondence, audit reports, spreadsheets, graphs, audit logs, anti-fraud software analysis, and appropriately sourced reference materials. Investigator ensures timely maintenance and organization of case file documentation with a high level of detail and accuracy that clearly and concisely outlines investigative steps, case synopses, and findings and to preserve as potentially discoverable material

Initiate claim adjustments, voucher deducts, and voluntary refunds in order to recover funds. Record recoveries and savings following established processes.

Perform special projects as assigned by management to meet the needs of the Special Investigations Unit.

Qualifications

Education Level: Bachelor's Degree

Experience: 2 years insurance, investigative, health care, nursing or law enforcement. In lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience.

Preferred Qualifications

· Credential in a health care or investigations related area such as Certified Fraud Examiner (CFE),

· Accredited Health Fraud Investigator (AHFI), RN/LPN, or Certified Professional Coder (CPC).

· Knowledge of ICD 10 and CPT® Codes, medical terminology, extensive training in claims and subscriber customer service methods, and previous experience in the health care industry.

Knowledge, Skills and Abilities (KSAs) Proficiency

· Knowledge of laws that pertain to public and insurance funds – Proficient

· Excellent communication skills both written and verbal. – Proficient

· Ability to recognize, analyze, and solve a variety of problems. – Proficient

· Ability to maintain effective interpersonal relationships – Proficient

***Lumen and / or its clients will not provide equipment (Laptop, monitor, etc.) to the selected contractor. The contractor must have their own equipment. Access to a virtual desktop set up (software) will be provided by Lumen’s client, allowing the user access to the required systems and technology. ***

Lumen Solutions Group Inc. is an Equal Opportunity Employer and does not discriminate in employment on the basis of Minority/Gender/Disability/Religion/LGBTQI/Age/Veterans.