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

📋 Description

• Create, implement, and oversee strategic initiatives to combat fraud, waste, and abuse while adhering to state and federal regulations and tracking emerging trends and schemes.

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

• Lead a team in thoroughly investigating all potential referrals related to fraud, waste, and abuse.

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

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

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

• Compile and circulate monthly and quarterly savings reports.

• Engage in Appeals Committee, workgroups, and interdepartmental meetings.

⛳️ Requirements

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

• A minimum of 4 years of experience in medical claim investigation, financial impact analysis, business analysis, compliance, or fraud and abuse is necessary.

• Comprehensive knowledge of medical terminology is essential.

• Prior experience in a managed care setting and as a lead or supervisor of staff, including hiring, training, assigning tasks, and managing performance, is preferred.

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

• Experience in pharmacy or with a Pharmacy Benefit Manager (PBM), and/or credentials or experience as a pharmacy technician is preferred.

• Certification as a Pharmacy Technician (CPhT) or a medical records or coding license is preferred.