Manager, Payment Integrity

This is a fully remote position, open to applicants in Florida, +4 more states.

📋 Description

• Develop, implement, and oversee strategic initiatives aimed at combating fraud, waste, and abuse, ensuring compliance with state and federal regulations while tracking trends and schemes.

• Monitor business operations and systems to guarantee integrity and adherence to billing and claims payment compliance.

• Lead teams of analysts in the investigation of potential fraud, waste, and abuse referrals.

• Create tailored fraud prevention plans to fulfill contract and federal obligations.

• Develop educational resources to help identify and confirm wasteful practices.

• Respond to requests for proposals (RFPs) and enact new policies in accordance with contractual requirements.

• Participate in state and federal meetings as mandated by specific contracts.

• Prepare and present the Fraud, Waste, and Abuse (FWA) program to state and federal officials during readiness assessments, following implementation, or in case of changes in state agency personnel.

• Review post-payment cases to recover funds.

• Prepare and distribute monthly and quarterly reports detailing savings.

• Perform additional responsibilities as assigned.

• Adhere to all policies and standards.

⛳️ Requirements

• Bachelor’s degree in Business, Healthcare, Criminal Justice, a related field, or equivalent experience.

• Over 4 years of experience in medical claim investigation, compliance, or fraud and abuse.

• Comprehensive understanding of medical terminology.

• Prior experience in a managed care setting is preferred.

• Previous leadership experience, including hiring, training, delegating tasks, and performance management, is preferred.

• A medical records or coding license is preferred.

🏝️ Benefits

• Competitive salary.

• Health insurance coverage.

• 401K retirement plan.

• Stock purchase options.

• Tuition reimbursement assistance.

• Paid time off, including holidays.

• Flexible work arrangements, including remote, hybrid, field, or office schedules.

• Additional incentive opportunities may be included in the overall compensation package.

• An equal opportunity employer dedicated to promoting diversity.