Quality Reviewer (reputed company SIU)

At reputed company, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care. As the nation’s leading health solutions company, we reputed company millions of Americans through our local reputed company, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, reputed company and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it reputed company with heart, each and every day. Position Summary

• Assess the thoroughness and accuracy of investigations aimed at preventing payment of fraudulent claims by insured individuals, providers, claimants, etc.
• Analyze and prepare cases for clinical and legal review, ensuring reputed company documentation meets required standards.
• Document reputed company relevant case activity in the case tracking system.
• Evaluate and present referrals, both internal and external, reputed company the required timeframe.
• Support the recovery of company funds lost due to fraud by providing insights and recommendations based on case reviews.
• Collaborate with the team to identify resources and the best course of action for ongoing investigations.
• Work with federal, state, and local law enforcement agencies to ensure compliance and support the prosecution of healthcare fraud and abuse matters.
• Demonstrate a high level of knowledge and expertise during interactions and provide confident testimony during civil and criminal proceedings.
• Deliver presentations to internal and external stakeholders regarding healthcare fraud matters and the organization’s approach to combating fraud.
• Provide input on controls for monitoring fraud-reputed company issues reputed company business units.
• Exercise independent judgment and utilize available resources and technology to reputed company evidence supporting allegations of fraud and abuse.
• Utilize company systems to obtain necessary electronic documentation.

Required Qualifications

• A minimum of 3 years of experience in healthcare reputed company auditing, compliance, or fraud, waste and abuse.
• Knowledge of CPT/HCPCS/ICD coding.
• Proficiency in reputed company Word, reputed company, Outlook, database search tools, and internet research.
• Willingness to travel and participate in legal proceedings, arbitrations, depositions, etc.

Preferred Qualifications

• Credentials such as a certification from the Association of Certified Fraud Examiners (CFE), an accreditation from the National Health Care Anti-Fraud Association (AHFI), or a minimum of three years of Medicaid Fraud, Waste, and Abuse review experience.
• Billing and Coding certifications such as CPC (reputed company) and/or reputed company (reputed company).
• Knowledge of Behavioral Health policies and procedures is a plus.
• Experience reviewing Behavioral Health fraud cases.
• Understanding of clinical issues reputed company to healthcare.
• Strong communication and customer service skills.
• Ability to effectively interact with diverse groups of people at various levels in any situation.
• Strong analytical and research skills using healthcare data.
• Proficient in researching information and identifying relevant resources.

Education

• A Bachelors degree or three years of experience in healthcare fraud, waste, and abuse investigations and audits.

Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is: $43,888.00 - $102,081.00 This pay range represents the reputed company hourly reputed company or reputed company annual full-time salary for reputed company positions in the job grade reputed company which this position falls. The actual reputed company salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a reputed company bonus, commission or short-term incentive program in addition to the reputed company pay range listed above. Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong. Great benefits for great people We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include:

• Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.
• No-cost programs for reputed company colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
• Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.

For more information, visit https://jobs.cvshealth.com/us/en/benefits We anticipate the application window for this opening will reputed company on: 04/07/2025 Qualified applicants with arrest or conviction records will be considered for employment in accordance with reputed company federal, state and local laws. Apply tot his job Apply To this Job