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PacificSource is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, national origin, sex, sexual orientation, gender identity or age.
Diversity and Inclusion: PacificSource values the diversity of the people we hire and serve. We are committed to creating a diverse environment and fostering a workplace in which individual differences are appreciated, respected and responded to in ways that fully develop and utilize each person's talents and strengths.
Position Overview: Assist in identifying potentially fraudulent claims. Review complex claim scenarios for final determinations. Review claim documents (i.e. medical records, operative reports, and diagnostic studies) and prepare documentation for utilization reviews. Determine investigative actions with the leadership team and perform follow-up investigations. Coordinate with law enforcement or state fraud bureaus for regulatory compliance and criminal activity trends. Initiate, analyze and resolve audits of mid to high level complexity in order to present FWA data to the leadership team for tracking and mitigation of exposure. Coordinate efforts to recover erroneous payments made due to processing errors, misrepresentative billing, fraud or abuse.
Essential Responsibilities:
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