Excellus Health Plan Inc.
Rochester, NY, USA
Job Description: Summary: Under the guidance of the SIU Management, this position is responsible for the accurate and thorough clinical investigation of potential fraud, waste and abuse (FWA) for all lines of business. The scope of accountability includes investigating and remediating allegations of FWA while adhering to compliance and regulatory requirements. Primary activities include substantiating referrals, case planning and research, conducting onsite or desk audits, clinical reviews of medical records to ensure correct billing of services and appropriateness of care, interviewing potential witnesses, developing corrective action plans, developing correspondence to impacted parties, managing disputes, and collaborating with law enforcement and regulatory agencies. Essential Accountabilities: Level I Functions as a clinical reviewer of medical records, researching and investigating complex medical cases. Interprets a variety of documents including, but not limited to...