SIU Investigator

At NTT DATA, we know that with the right people on board, anything is possible. The quality, integrity, and commitment of our employees have been key factors in our company's growth and market presence. By hiring the best people and helping them grow both professionally and personally, we ensure a bright future for NTT DATA and for the people who work here.

For more than 25 years, NTT DATA Services have focused on impacting the core of your business operations with industry-leading outsourcing services and automation. With our industry-specific platforms, we deliver continuous value addition, and innovation that will improve your business outcomes. Outsourcing is not just a method of gaining a one-time cost advantage, but an effective strategy for gaining and maintaining competitive advantages when executed as part of an overall sourcing strategy.

NTT DATA's Client is seeking a Investigator for Health Plan Special Investigations Unit ( "SIU ) REMOTE EAST COAST

The Investigator will be assigned to conduct pre-payment reviews of medical records for healthcare claims in one or more of the following areas: (1) Partial Hospitalization and Intensive Outpatient Programs; (2) Laboratory Testing; and/or (3) Durable Medical Equipment. The Investigator will work under the direction of an experienced pre-payment review investigator and work closely with other members of the SIU. Reviews are fast-paced and require the investigator to be organized and efficient in requesting records, reviewing documents, recommending outcomes, and coordinating claim dispositions (payment or denial) within the SIU and with internal business partners.

The Investigator will be responsible for the following:

Drafting and issuing letters to providers requesting clinical records and other relevant documentation
Utilizing case management systems to document case work, including correspondence, findings, and an investigative chronology
Evaluating claims by applying Plan policies and procedures and generally accepted industry standards of practice.
Preparing written summaries of findings, supported by evidence collected in the investigation
Assisting in the preparing fraud referrals to other SIU investigative staff, regulatory agencies, and law enforcement, when appropriate
Contacting members, providers, and other relevant parties to obtain additional information about assigned reviews

Qualifications:

1-3 year's related experience in health insurance fraud investigations, health insurance coding, provider relations, or another similar role
Bachelor's degree
Certified Fraud Examiner (CFE), Certified Professional Coder (CPC), or Accredited Health Care Fraud Investigator (AHFI) preferred
Familiarity with Partial Hospitalization and Intensive Outpatient Programs, Laboratory Testing, and/or Durable Medical Equipment preferred

Skills:

Demonstrated proficiency in Microsoft Word and Excel (including use of analytical tools such as Pivot Tables)
Organization and time-management skills

#LI-North America

About NTT DATA Services:

NTT DATA Services is a recognized leader in IT and business services, including cloud, data and applications, headquartered in Texas. As part of NTT DATA, a $30 billion trusted global innovator with a combined global reach of over 80 countries, we help clients transform through business and technology consulting, industry and digital solutions, applications development and management, managed edge-to-cloud infrastructure services, BPO, systems integration and global data centers. We are committed to our clients' long-term success. Visit nttdata.com or LinkedIn to learn more.

NTT DATA Services is an equal opportunity employer and considers all applicants without regarding to race, color, religion, citizenship, national origin, ancestry, age, sex, sexual orientation, gender identity, genetic information, physical or mental disability, veteran or marital status, or any other characteristic protected by law. We are committed to creating a diverse and inclusive environment for all employees. If you need assistance or an accommodation due to a disability, please inform your recruiter so that we may connect you with the appropriate team.