Manager, Payment Integrity – Policy Governance

📋 Description

• Design, execute, and oversee strategic initiatives to combat fraud, waste, and abuse while adhering to state and federal regulations and tracking trends/schemes.

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

• Lead teams of analysts to thoroughly investigate all potential referrals of fraud, waste, and abuse.

• Create tailored fraud prevention plans that align with contract and federal requirements.

• Develop educational resources to identify and validate waste activities as requested by the health plan and on an as-needed basis.

• Respond to RFP requests and implement new policies in accordance with contractual obligations.

• Attend state and federal meetings as mandated by specific contracts.

• Prepare and present the FWA program to state and federal personnel upon request, especially during readiness reviews, and immediately after go-live or changes in state agency personnel.

• Review post-payment cases with relevant stakeholders to facilitate refunds.

• Compile and distribute monthly and quarterly savings reports.

⛳️ Requirements

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

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

• Comprehensive knowledge of medical terminology is essential.

• Prior experience in a managed care setting and in a leadership role involving staff hiring, training, work assignment, and performance management is preferred.

• Familiarity with Microsoft Excel, medical coding, claims processing, and data mining is advantageous.

🏝️ Benefits

• Competitive pay

• Health insurance

• 401K and stock purchase plans

• Tuition reimbursement

• Paid time off plus holidays

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