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Special Investigations Unit Coordinator 7/25/2018

BMC HealthNet Plan Boston, MA

Boston, MA
AJE Ref #
Job Classification
Full Time
Job Type
Company Ref #
Entry Level (0 - 2 years)
Associates Degree




The SIU Coordinator is responsible for completing certain SIU processes including, but not limited to, the intake of cases triaged to the SIU, scheduling audits, ordering records, and tracking case information. The SIU Coordinator facilitates the opportunities for established metrics and target recovery goals to be achieved by the SIU Department. The SIU Coordinator may assist the SIU Manager in obtaining reports and metrics from vendors as well as other internal departments for internal or external reporting purposes. The SIU coordinator may have limited contact with providers, vendors and various State agencies regarding SIU cases or inquiries.

Key Functions/Responsibilities:

* Enters identified baseline triaged case information and subsequent process and documentation status updates into the case tracking system within prescribed time and quality parameters.

* Drafts audit notices as well as requests for records for final approval by SIU Manager.

* Receives and reviews requested case receivables to verify that all required documentation, including, but not limited to, HCFA1500 and/or UB04 claim forms, itemized bills, clinical service documentation, and pharmacy profiles, has been provided.

* Receives, reviews, and distributes correspondence received from external parties.

* Organizes case files for review and routes to the assigned investigator.

* Assists in the tracking and reporting of member eligibility issues, including, but not limited to, analyzing weekly denied claims reports to identify possible members residing out of state for further investigation.

* Processes claims adjustments, voids, corrected claims and returned checks following established Plan adjudication processes and quality metrics and department recovery guidelines and job aides.

* Monitors case-related due dates, keeping SIU Manager apprised of the status of open requests, per procedure.

* Provides complete administrative support to SIU staff.

* Coordinates SIU meetings, maintaining the meeting minutes.

* Interfaces with providers, vendors, and various State agencies to coordinate SIU meetings and, as assigned by the SIU Manager, projects.

* Manages record retention policies and procedures for compliance with HIPAA rules and regulations.

* Manages department calendars and maintains current and archived Plan and department policies, procedures, workflow, and/or job aid documents related to recurring activities.

* Develops and maintains positive professional relationships with providers and vendors and provides outstanding customer service to them. Identifies and escalates problematic provider, vendor and member issues to SIU management.

* Other responsibilities as assigned.

Supervision Received:

* General supervision is received weekly.



* Associate s Degree or the equivalent combination of education, training and experience within a health care or managed care organization.


* Basic medical terminology, CPT/HCPCS/ICD9 coding


* Minimum of 2 years experience as an administrative assistant or equivalent

* Minimum of 2 years experience with Microsoft Office

* Minimum of 1 years experience working with medical records

* Minimum of 2 years of medical billing, claims processing, or auditing experience


* Minimum of 4 years experience in a health care or managed care organization

* Working knowledge of Facets claims processing system.

Certification/Conditions of Employment:

* Pre-employment background check

* CPC or CCS certification a plus

Competencies, Skills, and Attributes:

* Demonstrated ability to plan, organize, and manage projects in order to meet established deadlines

* Detail oriented, with excellent proof reading and editing skills

* Strong oral and written communication skills

* Ability to interact within all levels of the organization

* Effective collaborative and process improvement skills

* A strong working knowledge of Microsoft Office and Excel products

* Must be team oriented

* Able to work in a fast paced environment and to multi task

* Proven ability to maintain confidentiality

Working Conditions and Physical Effort:

* Ability to work OT during peak periods

* Regular and reliable attendance is an essential function of the position

* Work is normally performed in a typical interior/office work environment

* No or very limited physical effort required. No or very limited exposure to physical risk

*Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status.

Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status. BMC HealthNet? Plan/Well? Sense Plan participates in the E-Verify Program to electronically verify the employment eligibility of newly hired employees.


Boston Medical Center Health Plan, Inc. (BMCHP) is a not-for-profit health maintenance organization founded in 1997 by Boston Medical Center. BMCHP’s Massachusetts business, BMC HealthNet Plan, serves over 260,000 members across the state and offers coverage to New Hampshire’s 115,000 Medicaid managed care program recipients. In New Hampshire, the organization operates under the name Well Sense Health Plan.Healthcare is one of the most dynamic and rapidly growing industries in the U.S. Working at our organization will challenge your knowledge and skills, while providing you with opportunities to participate in training and development programs that will help you achieve your professional goals. Whether it’s your first job or you want to take the next step in your career, we offer many rewarding positions in a welcoming, diverse work environment. Learn more about available job openings today.

Company Size:
501-1,000 Employees
Health Care
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2 Copley Place Suite 600
Boston, MA 02116

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