Medicare Payment Integrity Investigator -Remote

As a Medicare Payment Integrity Investigator you will partner with internal associates in our Medicare Claims division to identify opportunities where we can support the Medicare claims management process to minimize loss exposure to the organization.  You will play a key role in identifying and mitigating instances of fraud, waste, and abuse (FWA)—making a direct impact on our company’s ability to protect resources and uphold ethical standards. 

WHAT WE CAN OFFER YOU:

• Estimated Salary: $60,000 - $75,000, plus annual bonus opportunity
• Benefits and Perks, 401(k) plan with a 2% company contribution and 6% company match.
• Regular associates working 40 hours a week can earn up to 15 days of vacation each year.
• Regular associates receive 11 paid holidays in 2025, which includes 2 floating holidays that are added to your prorated personal time to be used at your discretion.
• Regular associates are provided sick leave through the use of personal time. Associates working 40 hours a week can receive up to 40 hours of personal time in 2025, which is prorated based on the start date. Additionally you will receive two floating holidays in 2025 by way of personal time that may be used at your discretion.
• Applicants for this position must not now, nor at any point in the future, require sponsorship for employment. 

WHAT YOU'LL DO:

• Performs review of healthcare claims to substantiate or refute the accuracy and compliance with federal and state regulations and contractual requirements of codes billed to identify coding errors and billing discrepancies in relation to incidents of suspected healthcare fraud, waste, and abuse (FWA). 
• Act as a liaison with 3rd party vendors, including identifying data trends, validating rules, making recommendations for improvement, and providing updates to management. 
• Proactively seeks out and develops leads from a variety of sources (e.g., CMS, OIG, HFPP, NHCAA) 
• Perform evaluation of leads, complaints, and/or investigations.  Conduct independent reviews resulting from the discovery of situations that potentially involve FWA, including communicating with medical providers and policyholders.  
• Develop appropriate recommendations and suggestions based on analysis and collaborate with management in the development of action plans where required. 

WHAT YOU’LL BRING:

• Seven+ years of advanced Medicare claims management and/or investigative experience. 
• Prior experience performing comprehensive reviews of Medicare healthcare claims to ensure accuracy, compliance with federal and state regulations, and alignment with contractual requirements. 
• Experience working with third-party vendors to identify data trends, validate coding rules, and recommend improvements that drive better outcomes. 
• Experience identifying and developing leads from trusted sources like CMS, OIG, HFPP, and NHCAA, evaluating them to uncover potential FWA cases. 
• In-depth knowledge of medical coding, billing practices, and healthcare regulations. In-depth understanding of ICD, CPT, HCPCS, DRG, revenue codes, NDC’s and other guidelines and general understanding of investigative processes within a healthcare environment are required.   
• You promote a culture of diversity and inclusion, value different ideas and opinions, and listen courageously, remaining curious in all that you do.
• Able to work remotely with access to a high-speed internet connection and located in the United States or Puerto Rico.

PREFERRED:

• Certified Professional Coder certification or equivalent 

We value diverse experience, skills, and passion for innovation. If your experience aligns with the listed requirements, please apply! 

If you have questions about your application or the hiring process, email our Talent Acquisition area at careers@mutualofomaha.com. Please allow at least one week from time of applying if you are checking on the status.

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