At Triple-S, we are committed to providing meaningful job experiences for Valuable People (Gente Valiosa). We strive for excellence in everything we do, from the way we work together to the way we serve our customers.
When you join Triple-S, you will be key to our efforts on delivering high-quality and affordable healthcare as well as contribute to our purpose to enable healthier lives. We serve more than 1 million consumers in Puerto Rico through our Medicare Advantage, Medicaid, Commercial, Life and Property & Casualty Businesses.
Let's build healthier communities together, join now!
JOB SUMMARY
Responsible for reducing medical costs by identifying Fraud, Waste and Abuse (FWA) in provider and member billing practices. Lead analysts and investigators for the validation of existing fraud waste and abuse business rules and leads designed to detect aberrant billing patterns and reviewing incoming referrals and leads to determine if additional investigations are warranted.
ESSENTIAL FUNCTIONS
- Lead and coach the Special Investigation Unit (SIU) team providing guidance in clinical record review, identifying and analyzing potential FWA risks and schemes, validation of medical coding, and ensuring the correct use of medical and payment policies, among others.
- Conduct reviews of clinical and, or pharmacy records and associated claims during fraud and abuse investigations or carrying out other benefit integrity initiatives by applying knowledge of coding guidelines, medical and payment policies procedures, Medicare policies, among others. Conduct interviews to members and providers to determine validity of claims and allegations or complaints.
- Process customer leads and referrals quickly and accurately, adhering to plan sponsor mandated turnaround times. Conduct proactive data mining and analysis if needed to identify suspicious billing patterns.
- Support and participate in special assignments such as conducting periodic internal or external review or audits to ensure that compliance procedures are followed, corrective actions implementation and external oversight activities support.
- Collaborate reviewing and interpretation of clinical files as part of the claims audit process. Interacts in peer-to-peer discussion with the audited, rendering and , or ordering provider to discuss claims audits results, reviews, determinations or disagreements, as requested.
- Discuss and collaborate with new rules and edits implementation based on FWA investigation’s findings with Medical Policy Department.
- Document and prepare written summaries of investigative steps, audit findings, conclusions, and recommendations.
EDUCATION
- Bachelor's Degree in Healthcare
EXPERIENCE
Bachelor’s degree (BD) in Healthcare or related field with one (1) to three (3) years of clinical experience in hospital field, Medical Policy and/or in Utilization Review experience.
Current professional valid license in Puerto Rico without restrictions. Certified Professional Coder (CPC)
LICENSES AND CERTIFICATIONS
COMPETENCIES
It is company policy to seek for the qualified applicants for positions throughout the company without distinction of race, color, national origin, religion, sex, gender identity, real or perceived sexual orientation, civil status, social condition, political ideologies, age, physical or mental disability, veteran status or any other characteristic protected by law. Drug-free company.
Equality Employment Opportunity/Affirmative Action for People with Disabilities/Veterans. Employer with E-Verify to verify the eligibility of employment of all the new employees.
We encourage Veterans and Disabled to Apply.