This job is responsible for the daily activities of the provider integrity department, detection and investigation of fraud, waste and abuse (FWA) and the recoupment of related over payments related to the company’s provider spending. The incumbent will function as a key leader guiding all of the daily activities for one or more strategic units within the department: investigative unit, vendor audit teams, technology and management reporting, FWA and financial recovery identification team, and regulatory compliance team.
Perform management responsibilities to include, but are not limited to: involved in hiring and termination decisions, coaching and development, rewards and recognition, performance management and staff productivity.
Plan, organize, staff, direct and control the day-to-day operations of the department; develop and implement policies and programs as necessary; may have budgetary responsibility and authority.
Deliver daily guidance to team leads and staff regarding case investigation activities including the development of detailed strategies for each case. Educate staff and management on regulatory and customer requirements regarding scope of activities and ensure adherence to these requirements. Serve as subject matter expert for staff on the fraud investigation, facility and vendor audit and opportunity teams.
Provide daily guidance to staff regarding investigations of various doctors, hospitals and other providers.
Develop action plans and priorities for various recovery opportunities with a focus on the continual increase in financial impact generated by investigation and analysis activities.
Actively communicate and collaborate with management from various departments regarding impact on provider relations and reimbursement.
Provide suggestions on and/or participate in department projects, process improvements, efficiency initiatives, system enhancements and policy and procedures to improve workflows.
Serve in a variety of capacities in representing the department, including but not limited to such activities as:
Work with audit vendors to refine their approaches and generate consistent increase in their recoveries.
Testify when required in legal proceedings.
Serve as liaison for the company’s customers as it relates to fraud, waste and abuse (FWA) program and fraud awareness trainings.
Collaborate with law enforcement in the pursuit of cases referred for prosecution
Interact with external legal counsel regarding case inquiries
Collaborate with other business units to ensure that appropriate policy and/or system changes occur to minimize fraud, waste and abuse (FWA) perpetrated against the company.
Assist in the communication of audit strategies throughout the company. Manage staff to ensure a culture of continuous improvement by all employees.
Implement processes to utilize data generated by technology tools to enhance investigations and vendor audits. Participate in external meetings/discussions to stay informed regarding current fraud, waste and abuse (FWA) schemes and potential investigation approaches to combat schemes. Work with management to develop quarterly opportunity assessments used to direct the development of data analytics, and focus the use of resources.
6 years' minimum experience in auditing, consulting and/or fraud, waste and abuse (FWA)
Master’s Degree - Business Administration
5 years' combined experience auditing, leading provider/facility audits and/or provider reimbursements, working with law enforcement, claims billing, coding, benefits, enrollment or external relationship management (vendors, regulatory agencies or healthcare industry groups).
3 years' combined experience of (1) overpayment identification resulting from claims billing including completion of inquiries on claim charges from providers or customers and/or from the claim processing operations (2) fraud, waste and abuse (FWA) investigations (3) audit consulting experience in the healthcare or Finance related fields with strong relationship and project management skills
3 years' combination of managerial/supervisory experience or leadership experience
3 years' related experience in claims analysis and/or investigations activities (for Operations area).
3 years' experience in provider claim review and recoveries
3 years' experience in fraud, waste & abuse (FWA) related investigations, utilization review payment or hospital reimbursement
Significant experience in monitoring and measurement of financial impact of activities
Strong and effective verbal and written communication skills; Effectively presents complex topics in a concise manner to audiences at various levels and various sizes; Demonstrates the ability to effectively persuade others to listen, commit, and act on a new approach
Knowledge of hospital reimbursement strategies; medical technologies, hospital and provider office protocols, documentation requirements, State and Federal criminal and civil law related to insurance fraud and advances in the post-payment utilization review process
Proven leadership skills - ability to motivate others to quickly achieve results in a matrixed environment; Successful experience in achieving results through people in a complex environment
Working knowledge of the various claims processing systems for professional and/or facility claims
Self-confident with an ability to accept and respond to challenges in a positive manner
Accredited Health Care Fraud Investigator (AHFI), Certified Fraud Examiner (CFE) or Certified Public Accountant (CPA)
Our businesses include the Highmark Health Plan, one of America's largest Blue Cross Blue Shield insurers; a growing regional hospital and physician network; and leading companies that offer dental solutions, reinsurance solutions, population health management, and innovative, technology solutions.
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