About The Position
Responsible for the strategic direction, planning, oversight, and operation of the Special Investigations (“SI”) and Program Integrity (“PI”) teams. Develops and directs the prevention, detection and investigation of anti-fraud, waste and abuse (FWA)program processes and oversight and coordination of all program integrity activities. Ensures all regulatory requirements are met including the completion of annual fraud plans and reports. Acts as a point of contact for collaboration with local, state and federal law enforcement and regulatory partners. Provides executive management with reimbursement or recovery recommendations based on PI team’s review of claims for appropriate coding, billed statistics, policies, industry standards and compliance with contractual, state, and federal regulation. Responsible for the management of the SIU and Program Integrity teams, their contracts and strategies and meeting the financial saving goals set by the enterprise. Work is typically performed in an office environment. Accountable for satisfying all job specific obligations and complying with all organization policies and procedures. The specific statements in this profile are not intended to be all-inclusive. They represent typical elements considered necessary to successfully perform the job.
Requirements
- Master's Degree- (Required)
- Minimum of 5 years-Managerial/Supervisory (Required)
- Minimum of 10 years-Health Insurance/Managed Care (Required)
- Computer Literacy
- Healthcare Industry
- Leadership
- Manages Conflict And Crisis
- Working Independently
Nice To Haves
- Bachelor's Degree-Business Administration/Healthcare Management
Responsibilities
- Provides leadership and strategic direction of Special Investigations and Program Integrity units spanning all lines of business.
- Ensures compliance with all regulators on anti-fraud and program integrity regulations.
- Presents to executive leadership the Privacy, Compliance and Program Integrity committee to report and communicate areas of non-compliance, risk, financial savings and potential fraud, waste or abuse
- Responsible for all PI & SI vendor relationships, including but not limited to, negotiating of contracts, adherence to key terms and ensuring contractual compliance.
- Leads teams through providing guidance, training, and counseling.
- Prepares and conducts performance appraisals to ensure team is high functioning and meeting both self and enterprise goals.
- Monitors workflow and production within the departments and prioritizes work accordingly.
- Coordinates interview process conducts interviews and initiates candidate selection.
- Partner with internal stakeholders to support product strategy and sales efforts with PI data.
- Collaborate with internal departments and maintain a dotted-line relationship with PI functions outside the direct organizational structure, including, but not limited to, Operations.
- Oversee the configuration, testing and maintenance of the SI and PI software, including upgrades, new release implementation, to ensure proper system set-up and operations for all activity.
- Oversee all external and internal Fraud, Waste and Abuse and Program Integrity audits.
- Responsible for Key Performance Indicators including claim edit and claim audit savings, dollars at risk, overpayment recoveries, referrals, as well as department return on Investment.
- Develops and executes a multi-year PI strategy aligned with financial goals set by the enterprise.
- Manages budget and financial performance for PI and SI.
Benefits
- We offer healthcare benefits for full time and part time positions from day one, including vision, dental and domestic partners.
- Perhaps just as important, we encourage an atmosphere of collaboration, cooperation and collegiality.
- We know that a diverse workforce with unique experiences and backgrounds makes our team stronger.
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What This Job Offers
Job Type
Full-time
Career Level
Director
