New Directions Behavioral Health Clinical Fraud Investigator-Kansas City, Missouri in Kansas City, Missouri

Responsible for the clinical analysis of claims data and review of medical records pertaining to claims audits and fraud, waste and abuse investigations. Assignments are generally of low to moderate complexity and focused primarily on clinical analysis of documentation supporting code billed and clinical appropriateness, but may also involve other areas such as: compliance with applicable laws and regulations, accreditation standards, and contracts. Works under supervision of the Manager of Claims Integrity with moderate latitude for initiative and independent judgment.

ESSENTIAL FUNCTIONS

• Reviews and analyzes provider and facility behavioral health claims (including inpatient, residential, partial hospitalization, intensive outpatient and outpatient), associated medical records and processes related to the appropriateness of coding, clinical care, medical necessity, documentation, and health care regulations.

• Conduct background research on provider and associated partners.

• Collect, organize, analyze, and disseminate significant amounts of information with attention to detail and accuracy.

• Compare to information submitted on the claims in order to determine amount and nature of billable services.

• Identifies trends and possible concerns related to potential inappropriate submission of claims by participating providers or facilities.

• Reviews and analyzes claims and medical records submitted by the provider or facility to determine appropriateness of billing and documentation as well as identify any quality of care concerns.

• Documents findings for each claim line with appropriate claims payment calculation in a findings spreadsheet.

• Summarize findings in a written report which will be provided to management, Plan, and in certain circumstances court proceedings.

• Responsible for maintaining current knowledge of coding guidelines and relevant federal and/or state regulations.

• Demonstrates high level of knowledge and expertise during interactions and acts confidently when providing testimony during civil and criminal proceedings.

• Responsible for interfacing with providers regarding compliance with all federal, state, and contractual regulations and obligations. Provide clear, concise and professional provider education in verbal and written format.

• Coordinates with various internal customers including Compliance, Legal, Clinical, Quality, Credentialing, Analytics and Network Operations to gather documentation pertinent to the investigation.

• Maintains documentation in appropriately organized files, databases, and systems to support audit work performed, detailed conclusions, and support any resulting recommendations.

• Participates in selected trainings and webinars to maintain a thorough understanding industry trends and changes.

• Assists in communicating the results of audit and consulting projects via written reports and oral presentations containing descriptive, analytical, and evaluative content to management, clients, and Providers.

• Maintains strict confidentiality of all provider, member, regulatory, and law enforcement sensitive information reviewed during the audit and/or investigation process.

• Completes audits or other assigned work within clearly specified time frames.

• Participates in on-going continuing education as required by professional licensure, certification, or as requested by New Directions and maintains clinical licensure and certifications

• Adheres to New Directions Behavioral Health Mission Statement, Core Values, Code of Business Conduct, and Compliance Program.

• Complies with all Federal and applicable State laws and New Directions Behavioral Health Policies regarding, privacy, confidentiality, and security of health information, and other designated information.

MARGINAL (NON-ESSENTIAL) FUNCTIONS

None

This list of duties and responsibilities is not intended to be all-inclusive and can be expanded to include other duties or responsibilities as deemed necessary.

JOB SPECIFICATIONS:

EDUCATION & EXPERIENCE

REQUIRED

• Master’s Degree in behavioral health field and has a current, unrestricted state license to practice independently as a Clinical Social Worker, Marriage and Family Therapist, Professional Counselor, Clinical Psychologist or Registered Nurse in the state in which the business operation is located and/or other states as required by law, regulation or contract.

• Minimum 3 -5 years of post-graduate direct clinical experience with patients in facility-based, outpatient psychiatric and/or chemical dependency treatment

• Strong analytical & investigative skills

• Ability to comprehend medical policy and criteria to clearly articulate health information

• Experience with all healthcare coding (CPT, HCPCS, DRG, ICD-10, & Revenue Codes)

• Excellent oral and written communication skills and an ability to communicate effectively with all levels of the organization.

• Intuitive nature to identify investigational leads regarding fraud, waste or abuse

• Ability to work independently & as part of a productive team

• Ability to handle multiple and conflicting priorities

• Working knowledge of medical review and medical record chart audits

• Proficient in Microsoft products, specifically Excel

PREFERRED

• Minimum of five (5) years post-licensure experience in direct clinical care with patients in facility-based, outpatient psychiatric and/or chemical dependence treatment

• Certified Professional Coder (CPC) or equivalent.

• 2+ years healthcare claims/reimbursement experience

• 2+ years related experience in healthcare, fraud investigations, managed care, or a related field.

• Proficient with all healthcare coding (CPT, HCPCS, DRG, ICD-10, & Revenue Codes)

• Familiar with healthcare claim adjudication standards & procedures

• Experience with SQL, Tableau or fraud analytics software

• Accredited Healthcare Fraud Investigator, Certified Fraud Examiner, Certified Insurance Fraud Investigator, Certified Public Accountant, Certified Internal Auditor, Certified Compliance Professional, or other similar licensure/certification

Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities

The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor’s legal duty to furnish information.

Qualifications