Fraud, Waste, and Abuse Investigations Manager

About the role

MedImpact Healthcare Systems, Inc. is seeking a Fraud, Waste, and Abuse Investigations Manager to handle operational activities related to Pharmacy Compliance and FWA. This role involves close partnership and collaboration with a cross-functional group of leaders, requiring outstanding program management, interpersonal, communication, and relationship building skills.

Responsibilities

• Handles fraud and abuse detection activities for state-defined PBA Programs, including the Fraud and Abuse Compliance Plan.
• Manages day-to-day Provider investigation-related inquiries.
• Utilizes prescription and medical claim data to generate clinical recommendations according to Global Drug Utilization Review program protocols.
• Shares clinical information and department procedure protocols during client site visits.
• Assists the FWA Team with new clinical programs and system enhancements.
• Performs other duties as assigned to meet departmental objectives.
• Investigates and remediates allegations of fraud, waste, and abuse involving providers.
• Interprets a variety of documents including client contracts, group benefit structures, Workplan Policies and Procedures, governmental policies, and diverse regulatory and legal requirements.
• Solves problems using sound professional judgment to determine the appropriate course of action and independently follows through, when necessary.
• Monitors regulatory interactions with the network of providers, prescribers, and members.
• Maintains case logs, prepares records and regular status reports.
• Interacts frequently with providers of health care, often under adverse conditions due to potential discovery of fraud, waste or abuse.
• Prepares comprehensive Reports of Findings and prepares cases for potential prosecution and civil settlement.
• Supports other FWA personnel and analysts with their cases by providing medical information/expertise and as necessary, performs clinical reviews of medical records for other FWA cases.
• Contributes to the development of medical procedural guidelines, protocols, and employee training.
• Provides back up for Supervisor/Manager, whenever necessary.
• Supervises and oversees the department, including developing and administering policies, business processes, and quality standards.
• Oversees operations between the BA/IT, Pharmacy Compliance, FWA, and FIST (EWA Impact.IU Team).

Qualifications

• Bachelor's degree from an accredited college or university required, advance degree highly desired.
• 4 - 6+ years' experience working in a lead investigative role.
• Prior experience in Asset Protection/Investigations setting with compliance exposure preferred.
• Strong proficiency with personal computers and MS Office products, including intermediate to advanced working knowledge of MS Word, Excel, Access, and Outlook.
• Familiarity with relational database systems and strong aptitude to learn and adapt to new programs.
• Continuous improvement of and training in data mining skills.