SIU Clinical Investigator

Key Responsibilities: Work with SIU Team (Clinical Reviewers, CPCs, Investigators, Analysts-including performing quality check on work, assisting in research, discuss to make appropriate coding determinations as needed).Analyze and interpret patient medical records pertaining to FWA investigations as needed. Compare information submitted on the claims to determine the amount and nature of billable services as needed. Determines appropriateness of billing and reimbursement as needed. Documents findings for each claim line in a spreadsheet as needed. Summarize findings in a written report as needed. Abstracts CPT, HCPCS, Revenue Codes, DRG codes, and ICD-9/ICD-10 from medical records as needed. Responsible for maintaining current knowledge of coding guidelines and relevant federal and/or state regulations as needed. Perform data analysis of client data as needed. Conduct various aspects of FWA investigations as needed. Provide Subject Matter Expertise and SIU support to clients as needed. Comply with Privacy and Security standards. Understands and complies with all company Privacy and Security standards. Employee may not use or disclose any protected health information, except as otherwise permitted, or required, by law. Other duties as needed.

Skills, Knowledge and Expertise: Knowledge of medical terminology. Knowledge of coding including CPT, HCPCS, Revenue Codes, DRG Codes, and ICD-10.Knowledge of specialty medical practices. Must be detail-oriented. Ability to communicate effectively both verbally and in writing. Strong listening skills. Independent. Responsible. Self-disciplined. Ability to meet defined performance and production goals. Strong computer skills. This job requires access to confidential and sensitive information, requiring ongoing discretion and secure information management.

About Healthcare Fraud Shield: Healthcare Fraud Shield, headquartered in Chesterfield, MO, is a leading provider of innovative fraud, waste, and abuse (FWA) solutions for healthcare insurance payers. Since its establishment in 2011, the company has focused solely on healthcare fraud prevention and payment integrity, delivering unique advantages to its broad client base. At the heart of Healthcare Fraud Shield's offerings is FWAShield™, an integrated platform designed by industry-leading healthcare experts. This comprehensive solution includes PreShield™ (pre-payment), PostShield™ (post-payment), RxShield™ (pharmacy analytics), CaseShield™ (case management), and QueryShield™ (ad-hoc querying tool). Leveraging the latest technology available, Healthcare Fraud Shield provides the most affordable, flexible, transparent, efficient, and effective solution in the marketplace. With over 20 years of experience, the founders of Healthcare Fraud Shield are pioneers in successful fraud detection software development in the financial services industry. They have designed their suite of software to identify superior FWA rates, utilizing advanced analytics, AI, and the best exterior data. Additionally, Healthcare Fraud Shield offers expert services in detecting and verifying suspected FWA billed services, including the development of claim edit rules. Their experienced SIU team, which includes Accredited Health Care Fraud Investigators and Certified Professional Coders, delivers top-notch training throughout the country. Trust Healthcare Fraud Shield to safeguard your healthcare insurance payments and ensure payment integrity.