Senior Investigator (Healthcare FWA) Provider Escalations

Senior Investigator (Healthcare FWA) Provider Escalations

As a Senior Investigator, you will investigate suspected incidents of healthcare fraud, waste, or abuse through data analysis (a high level of proficiency with Excel is required). This role will primarily support provider escalations related to Cotiviti's prepayment FWA services. This is not a physical investigator role.

Responsibilities :

• Act as the primary contact for escalated provider-related concerns related to Cotiviti's prepayment FWA service, ensuring timely and thorough resolution.
• Educate providers regarding Cotiviti claim determinations including review of coding and payment guidelines, plan policy, and other relevant sources.
• Partner with Cotiviti clients and internal client services staff to resolve provider complaints, schedule educational calls, disseminate relevant reporting and recommend subsequent investigative steps.
• Document and report detailed records of escalations, investigations, and outcomes. Prepare reports for internal and external use.
• Identify, investigate, analyze and evaluate instances of potential fraud, waste, and abuse.
• Conduct interviews or correspond with patients, providers, witnesses or other relevant parties to determine settlement, denial or review.
• Analyze information gathered by investigation and report findings and recommendations as a written summary and / or presentation.
• Conducts investigation-related training.
• Supports legal proceedings as needed, including testifying in court or working with law enforcement personnel to prepare cases for civil or criminal actions.
• Negotiates settlement agreements to resolve disputes.
• Maintain current knowledge of relevant laws, regulations and standards.
• Participates in special projects as required.

Qualifications :

Mental Requirements :

Physical Requirements and Working Conditions :

Base compensation ranges from $70,000 to $90,000 per year. Specific offers are determined by various factors, such as experience, education, skills, certifications, and other business needs. Cotiviti offers team members a competitive benefits package to address a wide range of personal and family needs.

Equal Opportunity Employer / Protected Veterans / Individuals with Disabilities