It’s an exciting time to join the WellSense Health Plan, a growing regional health insurance company with a 25-year history of providing health insurance that works for our members, no matter their circumstances.
The Clinical Investigator I, Special Investigations Unit (SIU) is responsible for the identification, investigation and prevention of healthcare fraud, waste and abuse, and is a key contributor to the Plan’s member and provider fraud, waste, and abuse (FWA) detection, investigation, remediation, and prevention efforts.
The Clinical Investigator I conducts data mining, utilizes preliminary recommendations provided by the SIU Data Analyst, and applicable guidelines and other sources of information to identify potentially fraudulent or abusive behavior. The Clinical Investigator I will also develop, conduct, resolve, document, and report on investigations of tips, allegations, or data mining output that suggests potentially fraudulent or abusive behavior. The Clinical Investigator I’s scope of work may range from independent evaluation of preliminary information to on-site audit to participation in Federal or State prosecution of a case. The Clinical Investigator may also review medical records for medical necessity based upon member diagnoses, clinical documentation and Plan policies as it relates to SIU investigations. In addition, the Clinical Investigator may conduct reviews of prescribers and members to determine if there appears to be overprescribing (particularly with controlled substances).
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Our Investment in You:
- Full-time remote work
- Competitive salaries
- Excellent benefits
Key Functions/Responsibilities:
- Receives cases triaged to the SIU from the Data Analyst, SIU, based on preliminary issue evaluation, priority, and approval of the Manager, SIU
- Acts as a clinical resource for non-clinical SIU investigators as needed should clinical questions arise
- Conduct clinical triage of incoming SIU referrals, identifying those providers/prescribers that appear to be outliers based upon member diagnoses, as well as patterns of provider prescribing habits
- Assist with SIU investigations that require a clinical review
- This may include but is not limited to medical necessity reviews based upon member diagnoses, clinical documentation and Plan policies, or conducting reviews of prescriber investigations to determine if there appears to be overprescribing
- Contributes to the identification of data mining algorithms based upon clinical criteria in order to identify potential FWA
- Assist in the clinical review of out of country claims in order to determine if services appear to be emergency services and covered under Plan policy, as well as to identify potential fraud
- Initiates case portfolio initially including Data Analyst’s findings; over the course of the investigation, expands portfolio to include such documentation as relevant Plan policies and procedures, member and/or provider publications (e.g., Evidence of Coverage or contracts), medical records and audit findings, interview records, etc.
- Reviews Data Analyst’s preliminary findings and requests pertinent additional data from the applicable parties including, but not limited to, the Data Analyst, SIU, or Contracting, Claims, Pharmacy, Provider Relations, Business Integration, and/or Customer Care departments
- Determines course of appropriate action based on line of business, severity of issue, and Plan exposure
- Collaborates with SIU Manager and/or Data Analyst to identify audit sample, either random or based on another approved methodology
- Conducts investigation including comprehensive review of any and/or all portfolio documentation and State-approved, where required, on-site or desk medical record review and/or member or provider interviews
- Creates detailed investigation report, including follow-up or remedial action recommendations, per department protocol and presents to department management
- Drafts preliminary investigation results documents for submission to provider or potential response to member
- Drafts Corrective Action Plan, where appropriate, and submits to SIU Manager for approval
- Coordinates with Provider Audit, Claims, Business Integration, Contracting, Compliance and/or Provider Relations staff when remedial actions such as pre-payment review, payment suspension, overpayment recovery, etc. dictate
- Updates department FWA database at prescribed intervals and per department standards
- As requested, participates in internal and/or external FWA-related information sharing sessions which may include receiving and providing secure data pursuant to contractual requirements
- Prepares summary and/or detailed reports on investigation findings for referral to Federal and state agencies which may include but are not limited to state Medicaid agencies, Medicaid Fraud Control Units, the Attorney General’s Office, the Department of Insurance, and local law enforcement
- Assists with FWA training for internal Health Plan staff
- Collaborates with department management on the data mining function including, but not limited to, specific activities and output necessary to support Investigator’s activities
- Meets all production deadlines
- Ensures accuracy and quality of work product by adhering to department’s data validation guidelines
- Regular and reliable attendance is an essential function of the position
Qualifications:
Education:
- Bachelor’s degree in Nursing or an equivalent combination of clinical education, training, and experience is required
- Valid Massachusetts or New Hampshire Registered Nurse License or equivalent clinical license required
- Basic familiarity of CPT, ICD-9, and HCPCS coding is required
Experience:
- Minimum of two years of experience in case management, utilization review or claims auditing
- Three to five years of experience in a health care payer setting
- Minimum of three years’ experience in a health care fraud control or similar investigative setting
Preferred/Desirable:
- Three years’ experience in the Managed Care industry preferred; two years’ experience in Medicaid Managed Care highly preferred
- Two years’ experience in a Medicaid or Medicaid Managed Care fraud detection unit (eg, Special Investigations/Program Integrity Unit, Recovery Audit Contractor, Medicaid Fraud Control Unit) highly preferred
- Prior External Auditing and/or Medical Record Review experience is preferred
- Claims processing experience a plus
Certification/Conditions of Employment:
- National Health Care Anti-Fraud Association certification (AHFI), Certified Fraud Examiner (CFE), or America’s Health Insurance Plans Health Care Anti-Fraud Associate (HCAFA) designation
Preferred/Desirable:
- Health care coding certification (CPC or CCS) highly preferred, and required within twelve months of employment
Competencies, Skills, and Attributes:
- Demonstrated proficiency with Microsoft Office products
- Time management skills necessary to meet established deadlines in a fast-paced environment, including the ability to re-prioritize tasks as workload and time constraints dictate
- Strong verbal and written communication skills with the ability to clearly articulate thoughts, ideas, processes and requirements to both internal and external audiences and in potentially contentious situations
- Attention to detail with excellent proof reading and editing skills
- Customer service skills with the ability to interact professionally and effectively with a wide variety of providers, third party payers, and staff from all departments within and outside the Plan
- Organization and analytical skills necessary to aggregate potentially disparate information from multiple sources
- Strong problem solving skills, including with the ability to determine root causes and to define workable solutions
- Ability to weigh alternatives and select the most appropriate course of action, given the individual circumstances of a case
- Creative thinking skills that allow one to ask the bigger-picture questions that lead to future improvements/gains
- Proven ability to maintain objectivity and the utmost confidentiality
Working Conditions and Physical Effort:
- Limited travel is required
About WellSense
WellSense Health Plan is a nonprofit health insurance company serving more than 740,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded in 1997, WellSense provides high-quality health plans and services that work for our members, no matter their circumstances.
- WellSense will require proof of COVID-19 vaccination(s) as a term of employment for all employees. The company may make exceptions to this requirement in certain limited circumstances for religious or medical purposes.
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