The Special Investigator Clinical participates in investigations and post-payment reviews as needed to ensure the financial and clinical integrity of the Vaya Health mental health, developmental disability, and substance abuse provider network. The person in this position will review claims, medical records, billing data and other relevant documentation from providers. The position is responsible for identifying and providing detailed reports of areas of incorrect coding, missing or insufficient documentation, suspected Medicaid fraud/waste/abuse, over utilization by providers and recipients, and ensuring services provided meet medical necessity requirements. This position may be responsible for completing investigations referred by the Division of Health Benefits (DHB) or in making necessary referrals to the Department of Health and Human Services Program Integrity Unit of DHB.
The Special Investigator Clinical will utilize established Vaya procedures to conduct inquiries into complaints, allegations, and referrals regarding suspected Fraud, Waste or Program Abuse, and will conduct investigations as needed. The position will review an appropriate sample of claims to determine a provider's compliance or non-compliance with program guidelines, obtain and review administrative records (by mail and/or on-site visits), review for medical necessity, conduct research, communicate with necessary contacts both in and outside Vaya, and make decisions on correct coding, billing, documentation and delivery of services. The position will create a record of overpayments and prepare written communication to the provider explaining the review of findings when applicable. The source of assigned cases may be from complaints made by members, stakeholders or providers in the community, specific issues identified by Vaya Management or staff, Fraud and Abuse Detection tools, or other government agencies, etc.
Master's Degree in Human Service field or in a related field and two years of experience in mental health, developmental disabilities and/or substance abuse programs. Prior experience in complaint investigations or Fraud, Waste and Abuse investigations a plus. Additionally, professional experience in physical or integrated health settings appreciated but not required. Must be licensed in North Carolina. Acceptable licensure includes HSP-PA, LCSW, LPA, LMFT, LPC, PhD or PsyD. Employee must maintain credentials including requirements for licensure (e.g., CEUs).
About Vaya Health
Vaya manages Medicaid, state and local funding for individuals with mental health and substance use concerns and intellectual/developmental disabilities.