Manager, Payment Integrity – COB/TTL Vended Programs

This is a fully remote position, open to applicants in Illinois, +3 more states.

📋 Description

• Design, execute, and oversee strategic initiatives aimed at preventing fraud, waste, and abuse while adhering to state and federal regulations and tracking emerging trends and schemes.

• Assess business processes and systems to ensure compliance and integrity in billing and claims processing.

• Lead teams of analysts in investigating potential referrals related to fraud, waste, and abuse.

• Create tailored fraud prevention plans to align with contract and federal mandates.

• Develop training materials to help identify and validate wasteful practices.

• Respond to Requests for Proposals (RFPs) and implement new policies in accordance with contractual commitments.

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

• Prepare and present the Fraud, Waste, and Abuse (FWA) program to state and federal officials during readiness reviews, after go-live events, or upon changes in state agency personnel.

• Review post-payment case scenarios with relevant parties to secure refunds.

• Generate and distribute monthly and quarterly savings reports.

• Undertake additional duties as assigned and adhere to all relevant policies and standards.

⛳️ Requirements

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

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

• Comprehensive understanding of medical terminology is essential.

• Experience in a managed care setting is preferred.

• Prior experience in a leadership or supervisory role, including hiring, training, assigning tasks, and performance management, is preferred.

• A medical records or coding license is advantageous.

• Ability to uphold state and federal regulations and fulfill contractual obligations.

🏝️ Benefits

• Competitive salary.

• Health insurance coverage.

• 401K retirement plan.

• Stock purchase options.

• Tuition reimbursement opportunities.

• Paid time off in addition to holidays.

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

• Additional incentives may be included in the overall compensation package.