• Us Citizen

• Green Card

• Corp-Corp

• Consulting/Contract

• UG :- - Not Required

• PG :- - Not Required

• No of position :- ( 1 )

• Post :- 29th Jul 2021

Description:
This position will be a member of the Payment Integrity team providing oversight in the development and implementation of new programs and rules including clinical and coding guidelines for Payment Integrity services. This role will represent payment integrity to vendor programs and serve as a liaison among internal departments, external customers and providers on payment integrity initiatives and audit results. The role will also help to develop effective, well-defined and supported processes and functions for purchaser populations, and will develop, in collaboration with the full payment integrity team, new programs and concept management to meet Payment Integrity goals.
 
Job Duties
·       Develop, implement and manage strategic fraud, waste and abuse activities by maintaining state and federal requirements and monitoring trends/schemes
·       Monitor business processes and systems to assure integrity and compliance in billing and claims payment
·       Lead teams of analysts to appropriately investigate all possible fraud, waste and abuse referrals
·       Develop customized fraud plans to meet contract and federal requirements
·       Develop educational materials to identify/validate waste activities as requested by the health plan and on an ad-hoc basis
·       Respond to RFP request and implement new policies per contractual obligation
·       Attend state/federal meetings as required by specific contracts
·       Prepare/present the FWA program to state/federal personnel upon request, specifically during readiness reviews, and immediately following the go live or upon state agency personnel changes
·       Review post-payment cases with appropriate parties to obtain refund
·       Prepare and distribute monthly and quarterly saving reports
 
Education/Experience
·       Bachelor’s degree in Business, Healthcare, or equivalent experience.
·       5+ years of medical claim investigation, compliance or fraud and abuse experience.
·       Thorough knowledge of medical terminology required.
·       Previous experience in managed care environment and as a lead or supervisor of staff, including hiring, training, assigning work and managing performance preferred.
·       Knowledge of Microsoft Excel, medical coding, claims processing, and data mining preferred.