Manager, Payment Integrity – Policy Governance
Job Description:
- 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
- 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
Benefits:
- competitive pay
- health insurance
- 401K and stock purchase plans
- tuition reimbursement
- paid time off plus holidays
- flexible approach to work with remote, hybrid, field or office work schedules
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