Job Description :
JOB SUMMARY (Summarizes the major purpose and primary responsibilities)
This job is responsible for the daily activities of the Financial Investigations & Provider Review (FIPR) department. The FIPR strategic plan focuses on the detection and investigation of fraud, waste and abuse (FWA) and the recoupment of related overpayments related to the company’s provider spending. The incumbent will function as a key leader guiding all of the daily activities for one or more strategic units within the department: investigative unit, vendor audit teams, technology and management reporting, FWA and financial recovery identification team, and regulatory compliance team.
ESSENTIAL RESPONSIBILITIES (Describes the critical tasks, duties and responsibilities of the position.)
- 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.
- Delivers daily guidance to team leads and staff regarding case investigation activities including the development of detailed strategies for each case. Educates staff and management on regulatory and customer requirements regarding FIPR’s scope of activities and ensure adherence to these requirements. Serves as subject matter expert for staff on the fraud investigation, facility and vendor audit and opportunity teams.
- Provides daily guidance to staff regarding investigations of various doctors, hospitals and other providers.
- • Develops action plans and priorities for various recovery opportunities with a focus on the continual increase in financial impact generated by investigation and analysis activities.
- • Actively communicates and collaborates with management from various departments regarding impact on provider relations and reimbursement.
- • Provide suggestions on and/or participate 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:
- • Working with audit vendors to refine their approaches and generate consistent increase in their recoveries
- • Testifying when required in legal proceedings
- • Serving as liaison for the company’s customers as it relates to fraud, waste and abuse (FWA) program and fraud awareness trainings.
- • Collaborating with law enforcement in the pursuit of cases referred for prosecution
- • Presenting provider/network appeal cases to Medical Review Committee (MRC); and/or providing technical expertise in evaluating/resolving cases
- • Interacting with external legal counsel regarding case inquiries
- • Collaborating with other business units to ensure that appropriate policy and/or system changes occur to minimize fraud, waste and abuse (FWA) perpetrated against the company.
- Assists in the communication of audit strategies throughout the company. Manages staff to ensure a culture of continuous improvement by all employees.
- Implements processes to utilize data generated by technology tools to enhance investigations and vendor audits. Participates in external meetings/discussions to stay informed regarding current fraud, waste and abuse (FWA) schemes and potential investigation approaches to combat schemes. Work with management to develop quarterly opportunity assessments used to direct the development of data analytics, and focus the use of resources.
- Other duties as assigned or requested.
Bachelor’s Degree- Business, Finance, Healthcare Admin
Substitutions (Acceptable substitutions in lieu of a degree 1 ½ years’ experience = 1 year college)
6 years’ minimum experience in auditing, consulting and/or fraud, waste and abuse (FWA)
Minimum: This section refers to the minimum years and type of applicable experience needed to perform the job. Minimum requirements must be non-comparative, objective, and relevant.
- 5 years’ experience auditing, leading provider / facility audits and/or provider reimbursements, or in the health care industry with exposure to billing, coding
- 3 years’ experience in (1) provider overpayment identification and settlement and/or (2) fraud, waste and abuse (FWA) investigations including interactions with federal, state, and local law enforcement and regulatory agencies including negotiating Provider/Facility overpayment settlements and/or (3) audit consulting experience in the healthcare field with strong relationship and project managementskills
- 3 years’ experience in Highmark Finance, Audit or Operations areas.
- 3 years’ managerial/supervisory experience
- 3 years’ related experience in claims analysis and/or investigations activities (for Operations area).
Preferred: This section refers to additional desired years and type of experience that the hiring manager would prefer, above and beyond the basic requirements of the job.
- Certified Public Accountant (CPA
- 3 years’ experience in provider claim review and recoveries
- 3 years’ of experience in fraud, waste & abuse (FWA) related investigations, utilization review payment or hospital reimbursement.
- Significant experience in monitoring and measurement of financial impact of activities
KNOWLEDGE, SKILLS & ABILITIES (List the attributes required to perform the job through demonstrated service, education or training)
- Strong and effective verbal and written communication skills; Effectively presents complex topics in a concise manner to audiences at various levels and various sizes; Demonstrates the ability to effectively persuade others to listen, commit, and act on a new approach
- Knowledge of hospital reimbursement strategies; 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
- 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
- Working knowledge of the various claims processing systems for professional and/or facility claims
- Self-confident with an ability to accept and respond to challenges in a positive manner
- Broad understanding of business issues, metrics, organizational linkages and customer value
- Strong organizational and analytical skills in addition to project leadership and management skills
- Comprehensive knowledge of legal and investigative procedures used in the detection and successful resolution of health care fraud/abuse cases
REQUIRED LICENSURE (Licenses that are required to perform the job)
Accredited Health Care Fraud Investigator (AHFI), Certified Fraud Examiner (CFE) or Certified Public Accountant
TRAVEL REQUIREMENT: 0% – 25%
(List % of time traveling)
LANGUAGE REQUIREMENT (other than English)?
(List primary language)
PHYSICAL, MENTAL DEMANDS AND WORKING CONDITIONS
(The physical, mental demands and working conditions described here are representative of those that must be met by an employee to successfully perform the essential function of their job. Reasonable accommodations will be made when necessary to enable individuals with disabilities to perform the essential duties of the position, to the extent that they do not cause undue hardship.
An employee in this position works in an office environment. The position frequently requires the employee to communicate effectively with others both inside and outside the workplace (e.g., in person, via telephone, via email). The employee must be able to understand, interpret and analyze data, solve problems, concentrate, and research, use available technological resources and systems (e.g., computers and computer programs), multi-task, prioritize, and meet multiple deadlines to complete essential tasks. The employee generally works in a fast-paced and frequently stressful environment, must attend work on a regular and reliable basis as well as adhere to all workplace policies, and may be called upon to work outside regular business hours.
Teaches/Trains others regularly Rarely
Travels regularly from the office to various work sites or from site-to-site Occasionally
Works primarily out-of-the office selling products/services (Sales employees) Does Not Apply
Physical Work Site Required No
Most On-The-Road Positions
An employee in this position may work in a home or company office environment but is also frequently driving to and from various locations to perform the work off-site. The position frequently requires the employee to communicate effectively with others both inside and outside the workplace (e.g., in person, via telephone, via email). The employee must be able to understand, interpret and analyze data, solve problems, concentrate, and research, use available technological resources and systems (e.g., computers and computer programs), multi-task, prioritize, and meet multiple deadlines to complete essential tasks. The employee generally works in a fast-paced and frequently stressful environment, must attend work on a regular and reliable basis as well as adhere to all workplace policies, and may be called upon to work outside regular business hours.
An employee in this position is frequently required to move throughout the workplace, sit, stand and walk, use hands and fingers to hold objects, tools or controls, possess fine motor skills (e.g., to write and operate a computer or to steer transportation equipment), possess gross motor skills (e.g., to carry items), reach with hands and arms, climb stairs and ladders, balance, stoop, kneel crouch and crawl, communicate effectively, and talk and hear. Specific vision abilities required by the job include close vision, distance vision, color vision, peripheral vision, depth perception, and the ability to adjust focus. The employee must be able to work in a busy environment where decisions often must be made quickly, must attend work on a regular and reliable basis, must adhere to all workplace policies, and may be called upon to work outside regular business hours. This work occurs in a [example: warehouse, hospital or provider’s office or mailroom].
Lifting: up to 10 pounds Occasionally
Lifting: 10 to 25 pounds Rarely
Lifting: 25 to 50 pounds Never
Changes Approved By:
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 position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies
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