We’re a health insurance company that acts like a technology company. We’re using software, data science and telemedicine to make health insurance more affordable, easier to access and more of a delightful experience
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The Case Management 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
Collaborate with medical professionals, forensic experts, and internal teams to gather relevant information and conduct thorough investigations
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.
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