Job Description

Join Us in Shaping the Future of Health Care

At MVP Health Care, we're on a mission to create a healthier future for everyone. That means embracing innovation, championing equity, and continuously improving how we serve our communities. Our team is powered by people who are curious, humble, and committed to making a difference-every interaction, every day. We've been putting people first for over 40 years, offering high-quality health plans across New York and Vermont and partnering with forward-thinking organizations to deliver more personalized, equitable, and accessible care. As a not-for-profit, we invest in what matters most: our customers, our communities, and our team.

What's in it for you:

• Growth opportunities to uplevel your career

• A people-centric culture embracing and celebrating diverse perspectives, backgrounds, and experiences within our team

• Competitive compensation and comprehensive benefits focused on well-being

• An opportunity to shape the future of health care by joining a team recognized as a Best Place to Work For in the NY Capital District , one of the Best Companies to Work For in New York , and an Inclusive Workplace .

You'll contribute to our humble pursuit of excellence by bringing curiosity to spark innovation, humility to collaborate as a team, and a deep commitment to being the difference for our customers. Your role will reflect our shared goal of enhancing health care delivery and building healthier, more vibrant communities.

Qualifications you'll bring:

• BA/BS degree in criminal justice or a related field, and minimum of five years ofinsurance claims investigation experience; or five years of professional investigation experience with law enforcement agencies, or seven years of professional investigation experience involving economic or insurance relatedmatters.

• A clinical investigator must have in addition to the above requirements: A duly licensed or authorized medical professional, including but not limited to MD or RN.

• New York State Nursing license required (RN preferred). Experience in health insurance fraud investigations preferred.

• Obtain CPC and/or COC credential.

• Maintain nursing license and coding credentials through continuing education process as required.

• Superior judgment skills, verbal and written communication, and presentation skills.

• Extremely detail-oriented with excellent organizational and analytical skills.

• Ability to utilize various data management tools to help identify potentially fraudulent activity.

• Possess knowledge of CPT-4, ICD-9-CM, ICD-10-CM, HCPCS and CPT Assistant coding guidelines as they relate to claim data.

• Working knowledge of MS Office (Word, Excel and Outlook)

• Curiosity to foster innovation and pave the way for growth

• Humility to play as a team

• Commitment to being the difference for our customers in every interaction

Preferred Job Skills:

• Working knowledge of Macess, Facets, CareRadius, Cognos, CMS web sites, and Encoder-Pro.

Your key responsibilities:

• Conduct clinical reviews of various forms of medical documentation and records obtained from providers and facilities including but not limited to medical charts, patient account records, and member interviews.

• Organize and conduct highly complex investigations. Document findings and recommendations throughout the investigative process in a timely and efficient manner according to corporate and departmental SIU policies and procedures.

• Act as an SIU liaison and interact with and analyze data in cooperation with Pharmacy, Medical Affairs, Operations, Provider Relations, Credentialing, Customer Care Center, Legal and other corporate personnel.

• Assist in investigations conducted by government agencies, law enforcement, and other insurance company SIU staff.

• Make recommendations for and conduct clinical re-audits of providers and facilities previously audited by SIU.

• Testify in criminal and civil legal case proceedings as necessary and assist outside legal counsel especially concerning issues needing clinical decision making.

• Participate in annual Corporate FWA training and training of new SIU personnel.

• Keep abreast of Federal and State Anti-Fraud investigation and reporting requirements including HIPAA, CMS, Medicare, Medicaid, and any corporate compliance initiatives or policies.

• Minimal travel may be required pertaining to investigations and audits.

• Contribute to our humble pursuit of excellence by performing various responsibilities that may arise, reflecting our collective goal of enhancing healthcare delivery and being the difference for the customer.

Where you'll be:

Virtual; Must reside within Eastern or Central Time Zone

Pay Transparency

MVP Health Care is committed to providing competitive employee compensation and benefits packages. The base pay range provided for this role reflects our good faith compensation estimate at the time of posting. MVP adheres to pay transparency nondiscrimination principles. Specific employment offers and associated compensation will be extended individually based on several factors, including but not limited to geographic location; relevant experience, education, and training; and the nature of and demand for the role.

We do not request current or historical salary information from candidates.

$69,383.00-$92,279.00

MVP's Inclusion Statement

At MVP Health Care, we believe creating healthier communities begins with nurturing a healthy workplace. As an organization, we strive to create space for individuals from diverse backgrounds and all walks of life to have a voice and thrive. Our shared curiosity and connectedness make us stronger, and our unique perspectives are catalysts for creativity and collaboration.

MVP is an equal opportunity employer and recruits, employs, trains, compensates, and promotes without discrimination based on race, color, creed, national origin, citizenship, ethnicity, ancestry, sex, gender identity, gender expression, religion, age, marital status, personal appearance, sexual orientation, family responsibilities, familial status, physical or mental disability, handicapping condition, medical condition, pregnancy status, predisposing genetic characteristics or information, domestic violence victim status, political affiliation, military or veteran status, Vietnam-era or special disabled Veteran or other legally protected classifications.

To support a safe, drug-free workplace, pre-employment criminal background checks and drug testing are part of our hiring process. If you require accommodations during the application process due to a disability, please contact our Talent team at [email protected] .

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