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Senior Medical Review Investigator (RN)

Company: HealthPartners
Location: Saint Paul
Posted on: January 8, 2021

Job Description:

We currently have an exciting opportunity for a Senior Medical Review Investigator (RN). This role will design, develop and maintain the clinical review/medical review function for the Claims or Fraud and Abuse area. They Investigate cases related to providers and enrollees of Medicaid, Medicare, and Commercial fully and self-insured products. They will provide analysis of claims processing and medical review protocols. This position includes the responsibility for managing and tracking impacted claims throughout the investigative process, and working with the Fraud and Abuse Manager on investigations. At HealthPartners, you'll find a culture where we live our values of excellence, compassion, integrity and most importantly, partnership. By working together, we will improve health and well-being, create exceptional experiences for those we serve and make care and coverage more affordable.ACCOUNTABILITIES:

  • Develop on-going medical review functioning claims processing. Analyze current procedures, design and implementation of medical review protocols.
  • Investigate cases related to providers and enrollees of Medicaid, Medicare, and Commercial fully and self-insured products.
  • Create and maintain medical review and/or fraud and abuse policy manual. Deliver or coordinate training for claims staff on medical review and/or fraud and abuse detection protocols and policies.
  • Perform on-going medical review of suspended claims to determine medical appropriateness and coverage eligibility. May approve or deny claims independently.
  • Develop and maintain tracking system to evaluate and report on review program effectiveness and cost savings. Identify areas that need to be changed or improved.
  • Work with staff and non-staff providers to gather medical information on referral claims and/or potential fraud and abuse cases.
  • Identify new procedures and technologies utilized in claims submitted. Develop and implement the review criteria to address new services.
  • Serve as primary contact with physician advisors to identify and develop medical review criteria for high abuse services and utilize a peer review mechanism for questionable claims.
  • Serve as the primary contact with the external vendor for on-going maintenance and customization of expert systems used for coding and review of medical appropriateness. Identify GHI needs and requirements and facilitate integration with GHI systems.
  • Communicate results of medical review to members and providers when appropriate.
  • Report and provide assistance as requested to regulators of Medicaid, Medicare, and Commercial fully and self-insured products.
  • Develop and coordinate the guidelines for fraud detection investigation.
  • Responsible for an investigative caseload. Accurately and thoroughly manage receipt, tracking and reporting of all case work in a timely manner. Monitor case referral volume.REQUIRED QUALIFICATIONS: (Minimum qualifications needed for this position)
    • Current professional license (RN).
    • 3-5 years experience in utilization review or medical field.
    • Advanced knowledge of health insurance industry and regulatory requirements affecting managed care.
    • Detailed knowledge of coding nomenclature and guidelines.
    • Concise and accurate written communication skills.
    • Excellent oral presentation skills.
    • Demonstrated leadership skills.
    • Excellent planning and organizing skills.
    • Effective human relations skills at all internal/external organizational levels.
    • Advanced analytical ability to assess situations and choose cost-effective solutions.
    • Ability to work and make logical decisions independently.
    • Demonstrated good judgment and investigative skills when reviewing potential fraud and abuse cases to identify schemes and likely cases.
    • Understanding and compliance with regulatory guidelines pertaining to fraud and abuse program requirements.PREFERRED QUALIFICATIONS:
      • 3-5 years experience in claim fraud and abuse investigations
      • Experience with HMO, fully insured, ASO and Indemnity products as well as government programs.
      • Prior experience in developing medical review programs.
      • Proficient with personal computers, word processing and spreadsheets.HealthPartners is recognized nationally for providing outstanding care and experience for patients and members. We offer an excellent salary and benefits package. For more information and to apply go to and search for Job ID#56912Additional Information:RN license requiredTravel needed between 180 and 8170 buildings and possibly related to investigationsWe are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class.

Keywords: HealthPartners, St. Paul , Senior Medical Review Investigator (RN), Healthcare , Saint Paul, Minnesota

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