SIU Investigator

Prominence Health is a value-based care organization bridging the gap between affiliated health systems and independent providers, building trust and collaboration between the two. Prominence Health creates value for populations and providers to strengthen integrated partnership, advance market opportunities, and improve outcomes for our patients and members. Founded in 1993, Prominence Health started as a health maintenance organization (HMO) and was acquired by a subsidiary of Universal Health Services, Inc. (UHS) in 2014. Prominence Health serves members, physicians, and health systems across Medicare, Medicare Advantage, Accountable Care Organizations, and commercial payer partnerships. Prominence Health is committed to transforming healthcare delivery by improving health outcomes while controlling costs and enhancing the patient experience.

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Job Summary: The Special Investigations Unit is responsible for investigating and resolving high complexity healthcare fraud, waste and abuse (FWA) by medical professional, facilities, and members. This position researches, gathers, and analyzes claims data, medical records, corporate policy, state/federal policy, and practice standards to identify trends, patterns, aberrancies, and outliers in provider billing behavior. Serves as a subject matter expert for other investigators. Responsible for conducting compliance audits, risk assessments, investigations, education relating to billing, coding, reimbursement, and documentations. This position is full-time.

Benefit Highlights:

• Loan Forgiveness Program
• Challenging and rewarding work environment
• Competitive Compensation & Generous Paid Time Off
• Excellent Medical, Dental, Vision and Prescription Drug Plans
• 401(K) with company match and discounted stock plan
• SoFi Student Loan Refinancing Program
• Career development opportunities within UHS and its 300+ Subsidiaries! · More information is available on our Benefits Guest Website: benefits.uhsguest.com

About Universal Health Services:

One of the nation’s largest and most respected providers of hospital and healthcare services, Universal Health Services, Inc. (UHS) has built an impressive record of achievement and performance. During the year, UHS was again recognized as one of the World’s Most Admired Companies by Fortune; and listed in Forbes ranking of America’s Largest Public Companies. Operating acute care hospitals, behavioral health facilities, outpatient facilities and ambulatory care access points, an insurance offering, a physician network and various related services located all over the U.S. States, Washington, D.C., Puerto Rico and the United Kingdom.

Qualification and Requirements:

• Bachelor’s Degree or equivalent years of relevant work experience in Health-Related Field or Insurance required
• Licenses/Certifications: Coding certification from an accredited organization (American Academy of Professional Coders or American Health Information Management Association) OR; RN, LPC, LCSW, LMHC.
• 2+ years of medical coding experience OR; RN, LPC, LCSW, LMHC, PT, OT or ST license and 2+ years of related clinical experience in the field of obtained license
• Experience in healthcare fraud investigations, auditing, data analytics or related field
• The following certifications are preferred: Accredited Healthcare Fraud Investigator (AHFI), Certified Fraud Examiner (CFE), and Certified Professional Coder (CPC)
• Ability to perform intermediate data analysis and to articulate understanding of findings
• Ability to work under limited supervision with moderate latitude for initiative and independent judgment
• Ability to manage demanding investigative case load
• Strong written skills with ability to compose detailed investigative reports and professional internal and external correspondences
• Intermediate proficiency level in Microsoft Office
• Effective listening and critical thinking skills and the ability to identify gaps
• Strong interpersonal skills, high level of professionalism, integrity and ethics in performance of all duties
• Excellent problem solving and decision-making skills with attention to details

EEO Statement

All UHS subsidiaries are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates. UHS subsidiaries are equal opportunity employers and as such, openly support and fully commit to recruitment, selection, placement, promotion and compensation of individuals without regard to race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status or any other characteristic protected by federal, state or local laws.

We believe that diversity and inclusion among our teammates is critical to our success.

Avoid and Report Recruitment Scams

At UHS and all our subsidiaries, our Human Resources departments and recruiters are here to help prospective candidates by matching skill set and experience with the best possible career path at UHS

and our subsidiaries. During the recruitment process, no recruiter or employee will request financial or personal information (e.g., Social Security Number, credit card or bank information, etc.) from you via email. Our recruiters will not email you from a public webmail client like Hotmail, Gmail, Yahoo Mail, etc.

If you suspect a fraudulent job posting or job-related email mentioning UHS or its subsidiaries, we encourage you to report such concerns to appropriate law enforcement. We encourage you to refer to legitimate UHS and UHS subsidiary career websites to verify job opportunities and not rely on unsolicited calls from recruiters.