Auditor/Investigator II

Job Summary:

Monitors the processing and reconciliation of incoming electronic medical records, importing of prepay claims and records, and generating other operation reports related to process of prepay claims. Supports research of prepay and post-pay record questions as well as research and return of misdirected documents.

Essential Functions:

• Monitors QMS procedures, work instructions, and job aids. Provides first level review for changes.


• Supports problem-solving solutions for system issues.


• Provides expertise for implementing, deactivation, monitoring, quality assurance, and reporting of prepay edits.


• Facilitates meetings and coordinates presentations.


• Tracks and analyzes data and reports for prepay committee edit effectiveness; creates presentations.


• Assigns incoming and outgoing external contractor communications; monitors completion of requests.


• Researches prepay and post-pay record questions. Reports quality assurance for appeal requests, recalculations, and redeterminations.


• Schedules coordination of ad hoc calls with external contractors or law enforcement; takes minutes.


• Reviews and comments on Medicare JOAs.


• Creates templates and content for the external contractor annual fraud and abuse training.

Level of Supervision Received:
Plans and arranges own work; works with manager to prioritize projects.

Education (can be substituted for experience):
Minimum Bachelor's Degree required

Work Experience (can be substituted for education):
2 - 4 years of experience required; 5 - 7 years preferred
Must have investigative experience, preferably in healthcare
Experience in SIU (Special Investigations Unit) or Insurance Company quality assurance or fraud preferred

Certification(s):
Certified Fraud Examiner preferred