Clinical Investigator

Company: Vaya Health
Location: Burlington
Posted on: January 25, 2025

Job Description:

LOCATION: Applicants need to live in North Carolina. The position can be remote, but the applicant must be able to travel to Vaya's Offices or within Vaya's Catchment as needed. GENERAL STATEMENT OF JOBThe Clinical Investigator works under the direct supervision of the Special Investigations Director in the Compliance Department. The Clinical Investigator participates in investigations and post-payment reviews to ensure the financial and clinical integrity of service delivery and payments made to providers in the Vaya Health closed network. The Clinical Investigator will review claims, billing data, perform clinical reviews of service documentation and will provide appropriate clinical recommendations. The Clinical Investigator is responsible for identifying and providing detailed reports of areas of incorrect coding, missing or insufficient documentation, suspected Medicaid fraud/waste/abuse, over utilization by providers and recipients, and ensuring providers meet medical necessity requirements. The Clinical Investigator will develop investigative summary reports and make applicable referrals to the NC Division of Health Benefits, and recommendations as necessary to providers associated with investigation findings/outcomes.ESSENTIAL JOB FUNCTIONSInvestigative Activities:* Utilize established Vaya procedures to conduct inquiries and investigations into complaints, allegations, and referrals regarding suspected Fraud, Waste or Program Abuse* Review healthcare claims to determine if provider payments were rendered in accordance with rules, regulations, service definition, service utilization, and contractual requirements* Determine correct coding, billing, documentation, delivery of services and potential violations of federal and/or state regulation or Medicaid guidelines* Review clinical appropriateness of documentation and service delivery methodologies for potential fraudulent or abusive practices* Perform investigative activities (desk review, virtual, and/or on-site), interview providers, members, and stakeholders, and review medical records to verify compliance with program policies and/or standards of healthcare, appropriateness of services or medical necessity* Provide education and technical assistance to providers as needed* Prepare reports and exhibits from the findings of provider investigations and develop recommendations or intervention strategies to correct or prevent abusive practices, including proposals to recover inappropriately paid monies or to suspend or terminate program participation* File Ethics Complaints for licensed providers when indicated* Refer suspected fraud cases to the DHB Office of Compliance and Program IntegrityAdministrative Activities:* Participate in both informal and formal appeal processes, defending their decisions before a Vaya reconsideration panel, hearing officers and administrative law judges* Provide litigation testimony as applicable* Work in conjunction with various regulatory bodies* Propose new fraud prevention edits for automated claims/billing system when new fraudulent schemes are discoveredSupport Activities:* Other duties as assigned including technical assistance and provider education based uponneed, area of expertise, special interests and availability of resources
KNOWLEDGE OF JOB* Intermediate level of knowledge of Local, State and Federal laws and regulations pertaining to insurance and/or healthcare services * Knowledge of healthcare service definitions, service documentation, and service utilization requirements * Demonstrate proficiency in researching, understanding, interpreting and application of government rules/regulations/policies * Knowledgeable of the application of medical necessity criteria and the ability to analyze the quality and necessity of healthcare services (inpatient and community based) * Extensive oral and written communication with providers, state and federal regulatory agencies, licensing entities, independent contractors, and members * Proficiency in the use of Microsoft office software (word & excel), web browsers, and email * Excellent decision-making abilities to determine the appropriate course of action during investigations and subsequent follow-up * Ability to organize priorities, perform multiple tasks concurrently and work efficiently with competing priorities * Ability to work autonomously, exercising sound judgement and problem resolution skills* Demonstrate strong attention to detail, precision and meticulous accuracy for all tasks* Ability to establish appropriate and respectful relationships/partnerships with persons with a wide range of ethnicities and abilitiesQUALIFICATIONS & CREDENTIALING REQUIREMENTS Master's Degree in Human Services or Related Field is required as well as: * Two years of experience in compliance, healthcare, or fraud investigation unit OR * Two years experience with Healthcare/Health Plan and experience completing compliance reviews and preparing written reportsLICENSURE & CERTIFICATION REQUIREMENTS* Licensure: Must be licensed in North Carolina. Acceptable licensure includes HSP-PA, LCSW, LPA, LMFT, LCMHC, PhD or PsyD. Employee must maintain credentials including requirements for licensure (e.g., CEU's).* Must obtain certification through the Council on Licensure Enforcement and Regulation (CLEAR) within 12 months of employment.PHYSICAL REQUIREMENTS Close visual acuity to perform activities such as preparation and analysis of documents; viewing a computer terminal; and extensive reading. Physical activity in this position includes crouching, reaching, walking, talking, hearing and repetitive motion of hands, wrists and fingers. Sedentary work with lifting requirements up to 10 pounds, sitting for extended periods of time. Mental concentration is required in all aspects of work.RESIDENCY REQUIREMENTS: The person in this position is required to reside in North Carolina or within 40 miles of the NC border.SALARY: Depending on qualifications & experience of candidate. This position is exempt and is not eligible for overtime compensation.DEADLINE FOR APPLICATION: Open until filledAPPLY: Vaya Health accepts online applications in our Career Center, please visit https://www.vayahealth.com/about/careers/.Vaya Health is an equal opportunity employer.

Keywords: Vaya Health, Burlington , Clinical Investigator, Healthcare , Burlington, North Carolina