Manager, Payment Integrity Insights & Innovation

About the role

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.

Responsibilities

• 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 requests 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
• Perform other duties as assigned
• Comply with all policies and standards

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
• Previous experience in managed care environment and as a lead or supervisor of staff, including hiring, training, assigning work and managing performance preferred

Qualifications

• Medical records or coding license preferred

Pay

$87,700.00 - $157,800.00 per year

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