Clinical Investigator Rochester, NY

Clinical Investigator job at MVP Health Care. Rochester, NY. At MVP Health Care, we're on a mission to create a healthier future for everyone - which requires innovative thinking and continuous improvement. To achieve this, we're looking for a Clinical Investigator to join #TeamMVP. This is the opportunity for you if you have a passion for problem solving and investigations, commitment to compliance and ethical standards and dedication to continuous learning and improvement.

• 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
  .

• BA/BS degree in criminal justice or a related field, and minimum of five years of insurance 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 related matters.
• 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

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

• 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.

Virtual;
Must reside within Eastern or Central Time Zone

MVP Health Care is committed to providing competitive employee compensation…