Deloitte Forensic Investigator - Senior Consultant in Washington, District Of Columbia
Are you an analytical, data-driven professional? Are you interested in a role that uses leading edge analytics and offers an opportunity to provide front line support to solve our clients most challenging problems associated with health care Payment Integrity / Fraud, Waste and Abuse detection and prevention? If so, the Forensic Analytics practice is the place for you!
Data analysts apply their specialized knowledge of data acquisition, management, analysis, and interpretation directly to healthcare data, providing actionable insights that Deloitte, our clients, decision-makers, and others can use. It s a great career choice for those who want to apply healthcare expertise in a novel and innovative way.
Forensic Analytics is a fast-growth practice within Deloitte Risk and Financial Advisory that centers around several of the hottest areas of business today analytics, forensic analysis, and litigation support and the specialized skills that make careers in these areas both fascinating and in high-demand. Our Analytics team makes extensive use of data, statistical and quantitative analysis, rules-based methods, and explanatory and predictive modeling to bring insights to client issues. Our work increasingly employs specialized competencies, such as advanced analytics, visualization, and geospatial techniques.
Work you ll do
Responsible for the analysis of provider and member claims data, and non-clinical review of medical records pertaining to claims audits and fraud, waste and abuse investigations.
Assignments are generally of low to moderate complexity and focused primarily on documentation supporting code billed and documentation requirements, but may also involve other areas such as:
compliance with applicable laws and regulations,
regulatory reporting requirements
Conduct investigations into healthcare cases to identify potential fraud, waste, abuse, or improper payment.
Perform and interpreting provider billing patterns to identify potential fraud, waste, abuse, or improper payment.
Conduct background research on provider and associated partners.
Collect, organize, analyze, and disseminate significant amounts of information with attention to detail and accuracy.
Compare to information submitted on the claims in order to determine amount and nature of billable services.
Identifies trends and possible concerns related to potential inappropriate submission of claims by providers or facilities.
Reviews and analyzes claims and medical records submitted by the provider or facility to determine appropriateness of billing and documentation.
Documents findings for each claim line with appropriate claims payment calculation in a findings spreadsheet.
Summarize findings in a written report which will be provided to management, Plan, and in certain circumstances court proceedings.
Interpret provider policy to validate proper payment was made.
Prepare and presenting complex written and verbal materials (reports, findings and presentations)
Conduct interviews with medical providers to validate services rendered.
Contribute to a strong client relationship through interactions with client personnel on investigation-related issues.
Contribute to new business proposals and client pursuits
Manage own personal and professional development; seek opportunities for professional growth and expansion of consulting skills and experience
Network and negotiate to identify and sell potential new services or expand existing engagements by leveraging client relationships
Generate marketplace eminence through the creation of intellectual property across a host of mediums including but not limited to: articles, whitepapers, webcasts and other audio-visual presentations
Works under supervision of the Claims Integrity, Manager with moderate latitude for initiative and independent judgment.
As the regulatory landscape continues to shift and grow in complexity, companies are facing unprecedented compliance challenges and close regulatory scrutiny. We provide solutions in health care compliance, risk and technology-driven managed services. Managing your financial, operational, and reputational risk to allow you to focus on what matters most - the patient, innovation, and the greater health care marketplace.
Bachelor s degree in Healthcare, Business, Computer Science, Mathematics a related field or equivalent experience.
2 years of Health Care Forensic, Investigative, and/or Discovery industry related experience
2 years in a technical or functional role
Medical records review and claims analysis experience.
Strong analytical & investigative skills.
Ability to comprehend medical policy and criteria to clearly articulate health information.
Experience with all healthcare coding (CPT, HCPCS, DRG, ICD-10, & Revenue Codes).
Excellent oral and written communication skills and an ability to communicate effectively with all levels of the organization.
Intuitive nature to identify investigational leads regarding fraud, waste or abuse.
Ability to work independently & as part of a productive team.
Ability to handle multiple and conflicting priorities.
Working knowledge of medical review and medical record chart audits.
Proficient in Microsoft products, specifically Excel.
Proven leadership skills demonstrating strong judgment, problem-solving, and decision-making abilities
Pre-sales, proposal, and RFP experience
Certified Fraud Examiner
Certified Professional Coder (CPC) or equivalent a plus
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