Develop, implement and manage strategic fraud, waste and abuse activities by maintaining state and federal requirements and monitoring trends and schemes
Monitor business processes and systems to assure integrity and compliance in billing and claims payment
Lead a team responsible for investigating fraud, waste and abuse referrals for prepay investigations
Develop educational materials to address/identify waste activities as requested by the health plan and on an ad-hoc basis
Attend state/federal meetings as required by specific contracts
Review pre-payment cases with appropriate parties for the purposes of developing resolution strategies
Prepare and distribute monthly and quarterly saving reports
Participate in Appeals Committee, work groups and interdepartmental meetings

Bachelor’s degree in Business, Healthcare, Criminal Justice, related field, or equivalent experience
4+ years of combined medical claim investigation, financial impact analysis, business analysis, compliance or fraud and abuse experience
Thorough knowledge of medical terminology
Previous experience as a lead or supervisor in a pre-payment process managing cross functional teams or supervisory experience including hiring, training, assigning work and managing the performance of staff preferred
Knowledge of Microsoft Excel, medical coding, claims processing, and data mining preferred.

Manager, SIU Prepay Investigations

Key skills