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

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
Medical records or coding license preferred

Manager, Payment Integrity – Readmissions

Key skills