Description:
Coventry Health Care is seeking a SIU Review Nurse in our Wichita, KS Service Center. The successful candidate will be responsible for the planning, design, production, and maintenance of learning content and courseware for identifying persons or organizations involved in suspicious claims activities. Conducts investigation of suspect claims. Maintains database/case files of abusive, fraudulent and/or potentially fraudulent claims. Participates in the recovery of wrongful payment to providers. Participates and prepares evidence for referral to appropriate state/federal agency as mandated. Assists with the identification and measures to prevent future payment of fraudulent/abusive providers.
ESSENTIAL RESPONSIBILITIES:
- Prospectively investigates and analyzes suspicious provider claims.
- Provides claim edit decisions on claims pended for suspect providers.
- Communicates findings to Medical Directors to ensure appropriate claim payment decisions based on medical necessity.
- Assists with obtaining data needed to assure compliance with regulatory agencies.
- Reviews reports created by the SIU Investigator and provides direction in referring fraudulent claims to appropriate regulatory agencies as mandated.
- Acts as the SIU Investigator's consultant in retrospectively identifying and recovering inappropriate payments.
- Assists with development, modification and presentation of internal training program on the Fraud and Abuse Program.
- Performs other duties as required.
Qualifications:
Basic Qualifications:
- Registered Nurse with a current state RN license. Bachelor’s degree or equivalent experience.
- 2 or more years experience in medical terminology, coding and claims handling.
- Demonstrated ability to navigate among clinical and research disciplines.
- Substantive knowledge of managed care operations. Strong clinical knowledge and skills.
- Some experience in conducting and interpreting quantitative/qualitative analysis.
Preferred Qualifications:
- Experience working in Special Investigations Unit (SIU) within the healthcare industry.
Other:
- Effective verbal and written communication skills.
- Demonstrated ability to work independently, manage multiple projects, and work in a fast-paced environment.
Coventry Health Care, a $12.2 billion Fortune 500 organization, is a national managed health care company with nearly 5.1 million members in all 50 states. At Coventry Health Care, we are driven to ensure that every person and organization we serve receives the greatest possible value for their health care investment. We do this by providing a full range of competitive products through our seven core businesses – Commercial Risk, Medicare Advantage, Medicare Part D, Medicaid, Workers' Comp Services, Federal Employees Health Benefits Plan and Network Rental.
We are committed to constantly improving our low-cost platform so that we can deliver the products and services that our customers want at a price they can afford. Coventry has the expertise, the experience, and the agility to craft the new products, the new processes, and the new service needed to make healthcare more accessible to all Americans.
We offer a competitive salary, excellent benefits (401K with company matching, comprehensive benefits including medical, dental, and tuition reimbursement), vacation and sick time. This is a highly visible role dealing with business partners across the division and corporation, and being a part of motivating a dynamic team!
Please apply directly to
http://jobs.coventryhealthcare.com
and refer to Req#1312124, SIU Review Nurse.
Coventry Health Care is an Affirmative Action/Equal Opportunity Employer, and we are committed to building a talented and diverse team.
Job: Professionals
Primary Location: Wichita, KS, US
Other Locations: Omaha-Nebraska-United States,Sunrise-Florida-United States,Scottsdale-Arizona-United States,
Organization: 10750 - Service Center - Central Admin
Schedule: Full-time
Job Posting: 2013-07-22 00:00:00.0
Job ID: 1312124
Coventry Health Care is seeking a SIU Review Nurse in our Wichita, KS Service Center. The successful candidate will be responsible for the planning, design, production, and maintenance of learning content and courseware for identifying persons or organizations involved in suspicious claims activities. Conducts investigation of suspect claims. Maintains database/case files of abusive, fraudulent and/or potentially fraudulent claims. Participates in the recovery of wrongful payment to providers. Participates and prepares evidence for referral to appropriate state/federal agency as mandated. Assists with the identification and measures to prevent future payment of fraudulent/abusive providers.
ESSENTIAL RESPONSIBILITIES:
- Prospectively investigates and analyzes suspicious provider claims.
- Provides claim edit decisions on claims pended for suspect providers.
- Communicates findings to Medical Directors to ensure appropriate claim payment decisions based on medical necessity.
- Assists with obtaining data needed to assure compliance with regulatory agencies.
- Reviews reports created by the SIU Investigator and provides direction in referring fraudulent claims to appropriate regulatory agencies as mandated.
- Acts as the SIU Investigator's consultant in retrospectively identifying and recovering inappropriate payments.
- Assists with development, modification and presentation of internal training program on the Fraud and Abuse Program.
- Performs other duties as required.
Qualifications:
Basic Qualifications:
- Registered Nurse with a current state RN license. Bachelor’s degree or equivalent experience.
- 2 or more years experience in medical terminology, coding and claims handling.
- Demonstrated ability to navigate among clinical and research disciplines.
- Substantive knowledge of managed care operations. Strong clinical knowledge and skills.
- Some experience in conducting and interpreting quantitative/qualitative analysis.
Preferred Qualifications:
- Experience working in Special Investigations Unit (SIU) within the healthcare industry.
Other:
- Effective verbal and written communication skills.
- Demonstrated ability to work independently, manage multiple projects, and work in a fast-paced environment.
Coventry Health Care, a $12.2 billion Fortune 500 organization, is a national managed health care company with nearly 5.1 million members in all 50 states. At Coventry Health Care, we are driven to ensure that every person and organization we serve receives the greatest possible value for their health care investment. We do this by providing a full range of competitive products through our seven core businesses – Commercial Risk, Medicare Advantage, Medicare Part D, Medicaid, Workers' Comp Services, Federal Employees Health Benefits Plan and Network Rental.
We are committed to constantly improving our low-cost platform so that we can deliver the products and services that our customers want at a price they can afford. Coventry has the expertise, the experience, and the agility to craft the new products, the new processes, and the new service needed to make healthcare more accessible to all Americans.
We offer a competitive salary, excellent benefits (401K with company matching, comprehensive benefits including medical, dental, and tuition reimbursement), vacation and sick time. This is a highly visible role dealing with business partners across the division and corporation, and being a part of motivating a dynamic team!
Please apply directly to
http://jobs.coventryhealthcare.com
and refer to Req#1312124, SIU Review Nurse.
Coventry Health Care is an Affirmative Action/Equal Opportunity Employer, and we are committed to building a talented and diverse team.
Job: Professionals
Primary Location: Wichita, KS, US
Other Locations: Omaha-Nebraska-United States,Sunrise-Florida-United States,Scottsdale-Arizona-United States,
Organization: 10750 - Service Center - Central Admin
Schedule: Full-time
Job Posting: 2013-07-22 00:00:00.0
Job ID: 1312124