Empower AI

Conducts moderately complex reviews of claims during fraud investigations or other program integrity initiatives. Applies Medicare guidelines, medical terminology, and experience in Medicare claims analysis to determine payment appropriateness. Reviews claims processing system files to detect fraudulent billing practices and vulnerabilities. Coordinates the written Investigative Summary Report.

Analyzes and reviews claims for accuracy, completeness and eligibility. Prepares and maintains reports and records for processing. Familiar with standard concepts, practices, and procedures within a particular field. Relies on limited experience and judgment to plan and accomplish goals. Performs a variety of tasks.

Designs and implements complex databases with respect to JCL, access methods, access time, device allocation, validation checks, organization, protection and security, documentation, guidelines, and statistical methods. Coordinates database architecture changes with database engineers. Directs the installation of database management systems, databases, tables and views.