Description

The Case Management & Care Coordination Associate is responsible for analyzing and reporting fraud, waste, and abuse data, managing the escalation of emergency cases, conducting mortality investigations, overseeing general case management and care coordination activities, managing at-risk cases, and monitoring ICU admissions of enrollees receiving healthcare services from providers within the Reliance HMO Providers network.

Responsibilities

• Analyze claims data, billing records, and other relevant information to identify patterns, anomalies, and potential cases of fraud, waste, and abuse
• Utilize data analytics tools and techniques to identify trends, outliers, and potentially fraudulent activities
• Manage the escalation of emergency cases, ensuring timely and appropriate interventions for enrollees in critical or life-threatening situations
• Collaborate with healthcare providers, emergency services, and internal teams to coordinate and facilitate emergency care and support
• Conduct investigations into cases involving the mortality of enrollees to determine the cause, identify potential gaps in care, and assess the quality of care provided
• Collaborate with medical professionals, forensic experts, and internal teams to gather relevant information and conduct thorough investigations
• Monitor ICU admissions of enrollees, ensuring appropriate utilization and timely interventions, assessing the necessity and appropriateness of continued stay in the ICU
• Maintain accurate documentation of emergency cases, including communication, actions taken, and outcome
• Ensure compliance with applicable laws, regulations, and company policies related to fraud, waste, and abuse investigations, emergency case management, mortality investigations, general case management, managing at-risk cases, and ICU admissions

Requirements

• Bachelor’s degree in medicine, nursing, or related disciplines
• Knowledge of healthcare operations, fraud prevention, and regulatory compliance.
• Experience in conducting fraud, waste, and abuse investigations is preferred.
• Knowledge of emergency management protocols and procedures.
• Familiarity with mortality review processes and quality improvement initiatives.
• Knowledge of legal and regulatory requirements related to fraud, waste, and abuse investigations, emergency care, and case management.
• Professional certifications in fraud examination, case management, or related fields (e.g., Certified Fraud Examiner, Certified Case Manager) are advantageous.