Manager, Payment Integrity - Platform Management
About The Position
Develop, implement and manage strategic fraud, waste and abuse activities by maintaining state and federal requirements and monitoring trends/schemes. Monitor business processes and systems to assure integrity and compliance in billing and claims payment. Lead teams of analysts to appropriately investigate all possible fraud, waste and abuse referrals. Develop customized fraud plans to meet contract and federal requirements. Develop educational materials to identify/validate waste activities as requested by the health plan and on an ad-hoc basis. Respond to RFP request and implement new policies per contractual obligation. Attend state/federal meetings as required by specific contracts. Prepare/present the FWA program to state/federal personnel upon request, specifically during readiness reviews, and immediately following the go live or upon state agency personnel changes. Review post-payment cases with appropriate parties to obtain refund. Prepare and distribute monthly and quarterly saving reports.
Requirements
- Bachelor’s degree in Business, Healthcare, Criminal Justice, related field, or equivalent experience.
- 4+ years of medical claim investigation, compliance or fraud and abuse experience.
- Thorough knowledge of medical terminology required.
Nice To Haves
- Previous experience in managed care environment and as a lead or supervisor of staff, including hiring, training, assigning work and managing performance preferred.
- Knowledge of Microsoft Excel, medical coding, claims processing, and data mining preferred.
- Medical records or coding license preferred.
Responsibilities
- Develop, implement and manage strategic fraud, waste and abuse activities by maintaining state and federal requirements and monitoring trends/schemes
- Monitor business processes and systems to assure integrity and compliance in billing and claims payment
- Lead teams of analysts to appropriately investigate all possible fraud, waste and abuse referrals
- Develop customized fraud plans to meet contract and federal requirements
- Develop educational materials to identify/validate waste activities as requested by the health plan and on an ad-hoc basis
- Respond to RFP request and implement new policies per contractual obligation
- Attend state/federal meetings as required by specific contracts
- Prepare/present the FWA program to state/federal personnel upon request, specifically during readiness reviews, and immediately following the go live or upon state agency personnel changes
- Review post-payment cases with appropriate parties to obtain refund
- Prepare and distribute monthly and quarterly saving reports
Benefits
- competitive pay
- health insurance
- 401K
- stock purchase plans
- tuition reimbursement
- paid time off plus holidays
- a flexible approach to work with remote, hybrid, field or office work schedules
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What This Job Offers
Job Type
Full-time
Career Level
Manager
