Manager, Payment Integrity Readmissions

Develop, implement and manage strategic fraud, waste and abuse activities for a healthcare organization, ensuring compliance with federal and state requirements.

Location: Remote

Salary: $87,700–$157,800/yr

Responsibilities

• 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

Requirements

• Bachelor’s degree in Business, Healthcare, Criminal Justice, related field, or equivalent experience
• 4+ 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

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 work schedules