Executive, Claims A&H (Medical Investigator)

Job Summary:
The Medical Claims Investigator - Nurse plays a crucial role in ensuring accurate and fair assessment of health insurance claims. This role involves the review of medical documentation, verification of treatment necessity, and collaboration with healthcare providers to gather essential information. This role will conducting in-depth analysis of medical claims, utilizing critical thinking skills to assess the validity of claims, and actively participating in the detection and prevention of fraud, waste, and abuse.

This role requires a combination of nursing expertise, analytical capabilities, and a commitment to upholding the highest ethical standards in healthcare.

Core Functional:
Investigate FWA in Health & Accident Claims, identify irregular claims behavior, request past medical history (PMH) from hospital, review and summarize PMH, collaborate with Underwriting Team on non-disclosures approach and policy management, rotate on Fax-Claims services and settle claims payment for hospital direct billing.

Responsibilities:

Medical Investigation Management (60%)

• Conduct thorough data analysis of medical claims to identify patterns, trends, and anomalies.
• Utilize statistical tools and methodologies to assess claim data for accuracy and consistency.

• Actively participate in the identification and investigation of potential cases of fraud, waste, and abuse.
• Collaborate with specialized anti-fraud units to report findings and contribute to fraud prevention efforts.

• Apply critical thinking skills to evaluate complex medical scenarios and make informed decisions on claim eligibility.
• Assess the legitimacy of medical procedures, treatments, and billing practices.

• Employ investigative techniques to gather evidence and information related to claims.
• Work closely with law enforcement or other authorities when necessary.

• Document findings and investigative processes in a clear and comprehensive manner.
• Prepare detailed reports on cases involving fraud, waste, or abuse.

• Provide training to colleagues on recognizing potential fraud indicators and best practices in claims investigation.
• Stay updated on industry trends and share knowledge with the team.

• Collaborate with specialized units within the organization dedicated to fraud prevention and investigation.
• Share insights and contribute to the development of fraud prevention strategies.

• Adhere to industry regulations and guidelines governing healthcare fraud prevention.

Medical Claims Management (40%)

• Examine medical claims for accuracy, completeness, and adherence to policy terms.
• Assess medical documentation to determine the necessity and appropriateness of treatments.

• Collaborate with healthcare providers to obtain additional information or clarification on medical procedures.
• Verify the authenticity of medical records and treatment plans through effective communication.

• Ensure that claims align with policy coverage and exclusions.
• Interpret and apply policy terms to make informed decisions on claim eligibility.
• Collaborates with Underwriting Team to review non-disclosure conditions and apply risk consideration.

• Utilize nursing expertise to assess the medical necessity of treatments and procedures.
• Evaluate the appropriateness of prescribed medications and therapies.

• Verify pre-authorization details for medical procedures.
• Confirm if referrals were required and appropriately obtained.

• Maintain thorough and accurate records of claim investigations.
• Generate reports detailing investigation findings and recommendations.

• Evaluate and coordinate benefits with other insurance policies as well as coordinate with other insurers.
• Ensure accurate information regarding the patient's coverage from multiple sources.

Qualifications:

• Registered Nurse (RN) or Nurse Practitioner (NP) license.
• 3-5 years of experience in hospital
• Experienced in Claims or Underwriting is advantage.

• Previous experience in medical claims investigation or a related field is preferred.
• Familiarity with health insurance policies and procedures.

• Strong analytical and critical thinking skills to assess medical documentation.

• Excellent communication skills to interact with healthcare providers and policyholders effectively.

• High attention to detail to identify discrepancies in medical records and claims.

• Understanding of healthcare regulations and compliance standards.

• Ability to work collaboratively with a multidisciplinary team.

• Ability to interpret complex datasets and identify irregularities.

• Understanding of legal and regulatory frameworks related to healthcare fraud investigations.

• Ability to adapt to evolving fraud schemes and industry trends.