Company :
Highmark Inc.Job Description :
JOB SUMMARY
This job is responsible for the execution of the strategic plan of the Financial Investigations & Provider Review (FIPR) organization. The strategic plan focuses on the detection and investigation of fraud, waste and abuse (FWA) and recoupment of related overpayments associated with the company’s provider spending. The incumbent will function as a champion and driving force in the development of hospital/facility reimbursement related strategies to audit, educate, and secure financial recoveries when necessary, and/or to develop action plans for cases referred to law enforcement, if applicable.
ESSENTIAL RESPONSIBILITIES
- Performs management responsibilities to include, but are not limited to: involved in hiring and termination decisions, coaching and development, rewards and recognition, performance management and staff productivity.
- Plans, organizes, staffs, directs and controls the day-to-day operations of the department; develops and implements policies and programs as necessary; may have budgetary responsibility and authority.
- Provides daily direction and oversight to management and team leads regarding case investigation activities including the development of detailed strategies for each case. Ensures management and staff are aware of all regulatory and customer requirements regarding the department's scope of activities and ensures adherence to all requirements. Provides executive review and sign-off for cases involving fraud, waste and abuse (FWA) at the provider and/or facility level.
- Provides strategic vision, development, planning, execution and leadership to the department regarding claims audits and investigations of various hospital and facility organizations and/or through special investigations by (a) working with senior management to define recovery opportunities based on spending and risk by provider type, (b) developing action plans and priorities for various recovery opportunities with a focus on the continual increase in financial impact generated by audits, vendor audits and analysis activities, (c) actively communicating with management from various departments regarding impact on provider relations and reimbursement, and (d) providing direction on and/or participating in department projects, process improvements, efficiency initiatives, system enhancements and policy and procedures to improve workflows. Serves in a variety of capacities in representing the department, including but not limited to such activities as: (a) managing matrix organizational and/or vendor relationships, (b) identifying new and/or modified reimbursement and medical policies, (c) serving as liaison for all company's customers as it relates to the company's fraud, waste and abuse (FWA) programs and fraud awareness training, (d) participates on Medical Review Committee (MRC), including being a key liaison to external professionals serving on the MRC; prepares and presents provider / network appeal cases; and/or providing technical expertise in evaluating and resolving cases, (e) communicating and partnering with external legal counsel regarding case inquiries, and (f) collaborating with other business units.
- Ensures that department personnel, including managers, team leaders and staff have a thorough understanding of audit, compliance and strategies imperative for department success. Ensures a culture of continuous improvement by all staff.
- Oversees the development of appropriate technology tools. Evaluates and implements innovative methods to identify fraud, waste and abuse (FWA), including cutting edge statistical analysis tools that detect over-utilization. Ensures that the department personnel communicates with external parties to stay informed regarding current fraud, waste & abuse (FWA) schemes and potential investigation approaches to detect, mitigate and resolve schemes.
- Other duties as assigned or requested.
EDUCATION
Required
- Bachelor's Degree in Business, Finance, Healthcare Administration
Substitutions
6 years experience in healthcare, provider reimbursement, providing contracting, fraud, waste, and abuse investigations, or related field.
PREFERRED EDUCATION
- Master's in Business Administration
EXPERIENCE
Required
- 10 years in the Healthcare Industry
- 5 years of:
- focusing on hospital administration, hospital and/or facility reimbursement, provider contracting, post payment utilization environment and/or consulting experience OR
- identifying and negotiating Professional Provider fraud, waste and abuse (FWA) settlements and/or healthcare audit consulting experience with strong project management and relationship management skills OR
- leading financial or managerial reporting using industry leading reporting technology such as Tableau and SAS
- 5 years in a management role
- 3 years in Claims Analysis and/or Investigations Activities (for Operations area)
Preferred:
- 5 years reviewing payments or hospital reimbursements
- 5 years in provider claim review and recoveries
- 5 years in positions requiring the monitoring and measurement of financial impact analyses
LICENSES or CERTIFICATIONS
Required
- None
Preferred
- Certified Public Accountant (CPA)
SKILLS
- Proven leadership skills – ability to motivate others to quickly achieve results in a matrixed environment; Successful experience in achieving results through people in a complex environment
- Self-confident with an ability to accept and respond to challenges in a positive manner. Ability to use an effective consultative approach in discussions, audits and communications
- Effectively presents complex topics in a concise manner to audiences at various organizational levels and meeting sizes
- Uses knowledge of industry and market trends to develop and champion long-term strategies. Broad understanding of business issues, metrics, organizational and customer values
- Strong organizational and analytical skills in addition to project leadership and management skills
- Ability to create comprehensive audit strategies to fulfill department objectives
- Knowledge of healthcare claims processing systems, medical technologies, hospital and provider office protocols, documentation requirements, state and federal criminal and civil law related to insurance fraud and advances in the post-payment utilization review process
- Comprehensive knowledge of legal and investigative procedures used in the detection and successful resolution of health care fraud, waste and abuse (FWA) cases
Language (Other than English):
None
Travel Requirement:
0% - 25%
PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS
Position Type
Office-based
Teaches / trains others regularly
Occasionally
Travel regularly from the office to various work sites or from site-to-site
Rarely
Works primarily out-of-the office selling products/services (sales employees)
Never
Physical work site required
Yes
Lifting: up to 10 pounds
Constantly
Lifting: 10 to 25 pounds
Occasionally
Lifting: 25 to 50 pounds
Rarely
Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.
Compliance Requirement: This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.
As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy.
Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.
Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.
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