Medical Provider Performance Executive
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Key skills for this role
About the Role
Nextcare seeks a Medical Provider Performance Executive to conduct investigations of healthcare providers for fraud, waste, and abuse. The role involves data mining, audits, and collaboration with legal and finance teams.
Key Skills for This Role
Responsibilities
- Fraud, Abuse and Waste detection and prevention from Medical providers for allocated regions/countries.
- Data mining and data analysis for conducting investigations on provider claims.
- Support and drive the savings target strategy as set by the Global head of MPM.
- Review files, gather information, collect evidence to detect fraud and abuse on claims.
- Document all evidence obtained in the investigation to substantiate meritorious claims, deny unjustified claims, recover inappropriate payments or recommend action.
- Participate in onsite Audits, in house claims audit and Mystery shopping campaigns.
- Support the Medical Provider Performance Manager with administration and support tasks.
- Prepare comprehensive investigative reports and analysis.
- Collaborate and communicate internally with associated departments (legal, finance, claims operations) and external clients and providers.
- Maintain provider relationship in coordination with MPM team.
Requirements
- Medical Background (MBBS doctor/Nurse/Paramedic)
- Coding Certification like CPC, CPMA, COC, or CCS
- Work experience in insurance industry with claim cycle management
- Expertise in Excel, Power BI, data analytics
- Thorough knowledge of various types of insurance fraud and investigation techniques
- Strong interpersonal/relationship skills
- Excellent written and verbal communication skills
- High degree of integrity, dependability, accountability and confidentiality
Full Job Posting
Position Overview
- This position is responsible for conducting objective, fair, thorough, unbiased and timely investigations of healthcare providers for fraud, waste and abuse committed against Allianz group or its Payers.
- The position requires ingenuity and creativity to obtain case information not readily available, along with the ability to work independently with minimum supervision.
Responsabilities
- Fraud Abuse and Waste detections and prevention from Medical providers for allocated regions/countries
- Data mining and data analysis are required for conducting investigations on provider claims.
- Support and drive the savings target strategy as set by the Global head of MPM
- Review files, gather information, collect evidence to detect fraud and abuse on claims
- Document all evidence obtained in the investigation in order to substantiate meritorious claims, to deny unjustified claims, to recover inappropriate payments or to recommend action against responsible parties
- Participate in onsite Audits, in house claims audit and Mystery shopping campaigns
- Support the Medical Provider Performance Manager with all administration and support tasks to drive Fraud detections and prevention.
- Assesses the scope and determine the methodology needed to carry out an efficient investigation.
- Prepare comprehensive investigative reports and analysis
- Collaborates and communicates internally with associated department’s ie legal, finance, claims operations as well as external clients and Providers.
- Consults with legal and regulatory authorities for cases that may involve legal action.
- Manages and ensures generation of periodic dashboards
Requirements
- Medical Background (MBBS doctor/Nurse/Paramedic)
- Coding Certification like CPC(Certified professional Coder), CPMA (Certified Professional medical Auditor, COC (Certified Outpatient Coder), CCS (certified Coding Specialist)
- Work experience in insurance industry with claim cycle management
- Expertise is excel, power BI, data analytics
- Expertise in general industry trends.
- A thorough knowledge of the various types of insurance fraud and the strategies and techniques used in their investigation and of federal and state regulations
- Strong interpersonal/relationship skills.
- Excellent written and verbal communication skills used for interviewing and corresponding with claimants, attorneys, doctors, law enforcement, etc.
- A high degree of integrity, dependability, accountability and confidentiality is required for handling information that is considered personal and confidential.
- Ability to analyze data and interpret results.
- Ability to adapt, meet the changing demands of work environment, any delays or other unexpected demands.
- Ability to treat people with respect under all circumstances, instill trust in others besides upholding the values of organization.
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