Special Investigations Coordinator

Position Description

Base pay is influenced by several factors including a candidate’s qualifications, relevant experience, and anticipated contributions to meet the needs of the business, along with internal pay equity and external market driven rates. The salary range displayed has not been adjusted for geographical location. This range has been created in good faith based on information known to Capital Blue Cross at the time of posting and may be modified in the future. Capital Blue Cross offers a comprehensive benefits packaging including Medical, Dental & Vision coverage, a Retirement Plan, generous time off including Paid Time Off, Holidays, and Volunteer time off, an Incentive Plan, Tuition Reimbursement, and more.

At Capital Blue Cross, we promise to go the extra mile for our team and our community. This promise is at the heart of our culture, and it’s why our employees consistently vote us one of the “Best Places to Work in PA.”

The SIU coordinator has a key function within the Special Investigations Unit and performs many tasks independently. The candidate is responsible for assisting the investigators through document management and facilitating the case lifecycle flow (monitoring for timeliness related to appeals offsets, etc.) The coordinator is able to manage assigned cases involving non-complex issues. This would include preparing the case information, researching contract provisions, reviewing billing and coding policies, developing the claim overpayment spreadsheets, writing the provider overpayment letter and following the case to completion. Responsibilities also include managing the fraud hot line and fraud mailbox, performing an initial assessment and triaging or redirecting as necessary.

Responsibilities And Qualifications

• Assist in the investigative process
• Document management & independently manages the medical records request process from request to receipt of records & Monitors for compliance related to the appeals process & Finalizes Refund/Warning letters/Exhibit documents and tracks receipt acknowledgement
• Create and format reports.
• Responsible for re-pricing spreadsheets using the claims adjudication system and accurately recording the results.
• Manages the offset process including monitoring timelines for starting offsets, preparing the offset documents, distributing for approval, and as needed tracking for completion.
• Referral Management
• Responsible for managing the fraud hotline, which includes, maintaining the message, triaging or redirecting calls, contacting the member for additional information, and when possible, resolving the member issue. All actions must be completed within timeline requirements
• Responsible for managing the fraud mailbox which includes the same responsibilities as above. Enters all new referrals into the Capital Blue Cross and FEP SIU case tracking systems.
• Manage SIU administrative functions
• F&A Committee & Meeting Material preparations & Maintaining agenda, minutes, scheduling
• Schedule conference/webinars and meetings
• Track restitution payments
• Member education F&A training.
• Provides coverage for Prepay Review Claim Specialist, including queue management in Workflow and entry of cases into the UM authorization system.
• Completes data requests to assist management in completion of annual reports and audit activities. Produces monthly reports to assist the staff in managing their respective caseloads.
• The advanced candidate will demonstrate the ability and have the experience to successfully self-manage the above tasks and to assume greater responsibilities.
• Be responsible for revising desktops and procedures related to job functions and to assist management with maintaining compliance with all policy and procedures.
• Able to expand scope of “cases” that can be independently managed
• Demonstrate the ability to identify and manage non-medical necessity cases (coding errors only)
• Consistently demonstrate innovative thinking through problem solving and process improvement recommendations
• Performs other duties as assigned.
  
  

Skills

• Must be able to self-manage responsibilities and seek assistance as needed as evidenced by the ability to set and prioritize work based on department/business demands and to focus on the necessary key tasks.
• Responsible for managing several processes with minimal oversight and be able to provide input on process changes for continued improvement and efficiency.
• Experience utilizing a PC and related software including Word, Excel, PowerPoint, SharePoint, Cloud based Applications, and Access.
• The advanced candidate will be able to demonstrate a high degree of efficiency with Microsoft products, including but not limited to creating and working with templates, using formulas, pivot tables, sorting and filter functions, in Excel using Access to create reports etc.
  
  

Knowledge

• Working knowledge of FACETS using the following applications: Claim’s Processing, Claim’s Inquiry, Customer Service, Member/Subscriber and Provider Inquiry.
• Working knowledge of ERNIE platform to review member service documentation and inquiries.
• Knowledge of medical terminology and clinical coding, including CPT, HCPCS, ICD-9 helpful.
• Advance candidate will have knowledge of provider billing processes.
  
  

Experience

• 3 years' claims, customer service experience or a comparable position.
• 2 years' working experience with FACETS.
• The advanced candidate will have 5 years' claims or customer service experience or comparable experience.
  
  

Education And Certifications

• High School diploma or G.E.D
• The advanced candidate will have additional educational experiences or certification related to the field (Criminal Justice, Business, Health Services, or Coding Certification (CPC), etc.
  
  

Work Environment

• Fast paced, with changing priorities with a need to adhere to various regulations and requirements.
• degree of accuracy is required in all components of the job.
  
  

Physical Demands

• While performing the duties of the job, the employee is frequently required to sit, use hands and fingers, talk, hear, and see.
• employee must be able to work over 40 hours per week.
• The employee must occasionally lift and/or move up to 5 pounds.
  
  

Other

• Travel may be required to attend onsite company meetings or trainings.
  
  

About Us

We recognize that work is a part of life, not separate from it, and foster a flexible environment where your health and wellbeing are prioritized. At Capital you will work alongside a diverse and caring team of supportive colleagues and be encouraged to volunteer in your community. We value your professional and personal growth by investing heavily in training and continuing education, so you have the tools to do your best as you develop your career.

And by doing your best, you’ll help us live our mission of improving the health and well-being of our members and the communities in which they live.

Capital Blue Cross is an independent licensee of the Blue Cross Blue Shield Association. We are an equal opportunity/affirmative action employer and do not discriminate on the basis of race, color, religion, national origin, gender, sexual orientation, gender identity, age, genetic information, physical or mental disability, veteran status, or marital status, or any other status protected by applicable law.