Clinical Investigator (Remote NC)

LOCATION : Must live in North Carolina or within 40 miles of the NC border. This position can be remote, but the applicant must be able to travel to Vaya's Offices or within Vaya's Catchment area as needed .

GENERAL STATEMENT OF JOB

The 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 FUNCTIONS

Investigative 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 Integrity

Administrative Activities :

Support Activities :

KNOWLEDGE OF JOB

EDUCATION & EXPERIENCE REQUIREMENTS

Master's Degree in Human Services or related field is required. Must have :

OR

LICENSURE & CERTIFICATION REQUIREMENTS

PHYSICAL REQUIREMENTS

RESIDENCY REQUIREMENT : The person in this position is required to reside in North Carolina or within 40 miles of the North Carolina border.

SALARY : Depending on qualifications & experience of candidate. This position is exempt and is not eligible for overtime compensation.

DEADLINE FOR APPLICATION : Open Until Filled

APPLY : Vaya Health accepts online applications in our Career Center, please visit https : / / www.vayahealth.com / about / careers / .

Vaya Health is an equal opportunity employer.