Clinical Fraud Investigator II - (Frankfort, KY)

Responsible for identifying issues and/or entities that may pose potential risk associated with fraud and abuse. MAJOR JOB ASSIGNMENTS AND RESPONSIBILITIES: Conducts data mining activities using available tools and internal data warehouse. Performs comprehensive analysis and clinical evaluation of the collected data. Performs in-depth investigations on identified providers as warranted. Examines random claims for compliance with relevant billing and processing guidelines and to identify opportunities for fraud and abuse prevention and control. Researches new healthcare related questions as necessary to aid in investigations. Collaborates with the Special Investigation Unit and other internal areas on matters of mutual concern. Recommends possible interventions for loss control and risk avoidance based on the outcome of the investigation.