Manager, Payment Integrity Insights – Innovation

This is a fully remote position, open to applicants in Missouri.

📋 Description

• Develop, implement, and oversee strategic activities related to fraud, waste, and abuse.

• Ensure compliance with state and federal regulations while monitoring trends and schemes.

• Oversee business processes and systems to ensure integrity and compliance in billing and claims payments.

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

• Create tailored fraud prevention plans to meet contract and federal requirements.

• Produce educational resources aimed at identifying and validating wasteful activities.

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

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

• Prepare and deliver presentations on the FWA program to state and federal officials.

• Review post-payment cases to secure refunds.

• Compile and circulate monthly and quarterly savings reports.

• Execute additional duties as assigned.

• Adhere to all policies and standards.

⛳️ Requirements

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

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

• Extensive understanding of medical terminology.

• Previous experience in a managed care setting is preferred.

• Prior experience in a leadership role, including hiring, training, assigning work, and managing performance is preferred.

• A medical records or coding license is preferred.

🏝️ Benefits

• Competitive pay.

• Health insurance.

• 401K plan.

• Stock purchase plans.

• Tuition reimbursement.

• Paid time off in addition to holidays.

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

• Additional incentives may be included in total compensation.