Senior Compliance Analyst and SIU Investigator

POSITION SUMMARY

Under the supervision of the Chief Compliance and Health Equity Officer (CO) help ensure Community Health Group (“CHG”) complies with applicable federal, State, and local laws, regulations, and contract requirements through the creation and maintenance of an effective compliance program.  This position serves as an investigator in the Special Investigations Unit.

Position Purpose:
Audit medical records to identify inappropriate billing practices and recommend next steps through extensive review of claims data, medical records, corporate policy, state/federal policy, and practice standards.

Key Details:Preferred qualifications include coding certification, nurse coding experience, and experience with CPT coding.

• Perform retrospective and prepayment reviews of medical records to identify potential abuse and fraud and inappropriate billing practices
• Investigate, analyze, and identify provider billing patterns to recommend payment based on medical records, claim history, billing codes, regulatory and state guidelines, and policies
• Prepare summary of findings and recommend next steps for providers
• Identify preventative measures and recommend changes to internal policies and procedures and/or provider practices to prevent future fraudulent and erroneous practices
• Consult with other investigators to identify abuse and fraud by utilizing clinical and coding expertise to analyze patterns in billing activities

COMPLIANCE WITH REQUIREMENTS

Comply with all applicable legal and compliance requirements, including but not limited to federal and State laws and regulations; privacy, confidentiality, and information security mandates; and CHG policies and procedures.

POSITION DUTIES

• Assist in the management of day-to-day operations of the Compliance Department.
• Contribute to the achievement of established Department goals and objectives and adhere to Department policies, procedures, and standards.
• Organize and maintain inventory of Compliance Department policies and procedures.
• Maintain a strong working knowledge of all applicable legal, regulatory, contractual, and accreditation requirements.  Update job knowledge by participating in educational opportunities and reading professional publications.
• Perform special projects as requested.
• Discharge other duties as may be required in the course of business or as may be assigned by the CO.

Fraud Waste and Abuse Prevention and Detection Program (“FWA Program”)

• Serve as the SIU investigator.
• Under the direction of the CO, timely and comprehensively coordinate, monitor, and perform duties related to CHG’s FWA Program, including investigations, CAPs, education and training, and FWA Program development and risk management. 
  • Case Investigation: Evaluate, investigate, and resolve high-volume claims flagged for potential fraud (e.g., staged accidents, exaggerated medical injuries, arson).
  • Evidence Gathering: Utilize public records, database searches, forensic tools, and field interviews with witnesses and claimants to gather evidence.
  • Regulatory Compliance: Ensure all investigations adhere to California Department of Insurance regulations, Centers for Medicare & Medicaid (CMS), Department of Health Care Services (DHCS), and Department of Managed Health Care (DMHC) and other statutory requirements.
  • Reporting and Documentation: Prepare detailed, objective, and comprehensive reports summarizing investigation findings for claims, legal, and law enforcement partners.
  • Liaison and Training: Act as a subject matter expert on fraud, maintaining relationships with law enforcement and providing fraud awareness training to internal teams.
  • Surveillance (If applicable): Conduct field surveillance to verify claims.
• Work with all CHG stakeholders to ensure the FWA Program requirements are accomplished in a timely, comprehensive, and effective manner, in accordance with CHG’s FWA policies and procedures, and in compliance with applicable State and federal regulatory, legal, and contractual requirements.
• Track and provide FWA Program reports on a regular basis, and as directed or requested.

Privacy Compliance Program

• Under the direction of the CO, timely and comprehensively coordinate and assist in the implementation and maintenance of the Compliance Program. 
• Assist in the investigation of potential privacy incidents. 

• Assist with and track responses to regulatory inquiries, investigations, data, and other requests.
• Under the direction of the CO assist with the coordination of the CMS, DMHC and DHCS audits.
• Serve as one of CHG’s Compliance Department liaisons with regulatory agencies, including for responses to State inquiries, audits, and report requests.  Assist in the drafting and review of responses to regulatory agencies.

Qualifications

Key Details:Preferred qualifications include coding certification, nurse coding experience, and experience with CPT coding.

• Perform retrospective and prepayment reviews of medical records to identify potential abuse and fraud and inappropriate billing practices
• Investigate, analyze, and identify provider billing patterns to recommend payment based on medical records, claim history, billing codes, regulatory and state guidelines, and policies
• Prepare summary of findings and recommend next steps for providers
• Identify preventative measures and recommend changes to internal policies and procedures and/or provider practices to prevent future fraudulent and erroneous practices
• Consult with other investigators to identify abuse and fraud by utilizing clinical and coding expertise to analyze patterns in billing activities

Education/Experience:Associate's Degree related field or equivalent experience preferred
2+ years related clinical experience in the field of obtained license required
Provider education preferred

Licenses/Certifications:
Coding certification from an accredited organization (American Academy of Professional Coders or American Health Information Management Association), RN, LPC, LPN, LCSW, LMHC, PT, OT, or ST or related license. required

The above statements describe the general nature and level of work being performed. They are not intended to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified

All qualified applicants will receive consideration for employment based on merit, without regard to race, color, religion, sex, national origin, disability, protected Veteran Status, or any other characteristic protected by applicable federal, state, or local law.