Responsible for the development of the strategic goals and initiatives that inform the work of the Provider Audit and Special Investigations department. Defines, leads, and oversees the activities of the Provider Audit team and the Special Investigations Unit (SIU) related to the detection, audit or investigation, and resolution of provider error, waste or abuse cases or of member or provider fraud against the Plan.
Designs, implements and monitors strategies to ensure that the Plan pays only for medically necessary services provided to eligible members by eligible provider and the services are billed in accordance with Plan policies and provider contracts.
Leads the day-to-day operations of the Special Investigations Unit, including mining and analyzing data to identify and investigate trends, outliers and leads; correcting provider deficiencies through various remedial actions; and prevent member fraud and provider abuse and fraud against the Plan. If designated by the Compliance Officer, acts as a Medicaid Fraud, Waste and Abuse Coordinator.
Develops, reviews, and revises operational and administrative policies and procedures ensuring policies comply with contractual and regulatory obligations and align with the Plan’s philosophy and objectives as they relate to fraud, waste and abuse and are consistent with Plan corporate and cross-department policies and procedures
Maximizes financial recovery, where appropriate, and ensures that savings and recoveries plus the deterrent effects of the department’s activities have a positive impact on the Plan’s overall health care expenditures.
Establishes or approves documentation standards and systems used by the department’s functional areas, ensuring that documentation supports downstream referrals (e.g. to governmental offices such as Attorneys General or Medicaid Fraud Control Units).
Develops, implements and continually refines reporting processes, including those supporting regulatory reports and dashboards and trend reports for senior management.
Assesses department roles against business plan objectives and modifies as needed to meet stated or revised objectives.
Directs the supervision of subordinate staff to include hiring, performance management, work allocation, scheduling, training and professional development, problem resolution, and related supervisory activities.
Directs communications with state and/or federal agencies, including those related to periodic regulatory agency oversight audits of Plan Program Integrity activities.
Collaborates with other internal stakeholders (e.g., system configuration, provider relations, and finance departments) on process or performance issues related to department activities.
Represents the fraud, waste and abuse function on various Plan committees, as appropriate (e.g., compliance, payment policy development, utilization trend management).
Collaborates with the Chief Medical Officer and/or other interested parties to determine an appropriate response to a provider where concerns have been identified regarding potentially abusive or fraudulent practices or where the peer review process is invoked.
Participates in the Plan’s strategic planning efforts as a member of senior leadership.
Develops and monitors the annual department budget, ensuring alignment with division and organizational goals.
Directly supervises 3-5 staff. Indirectly supervises 10-15 staff.
General supervision is received weekly.
Degree in a clinical discipline (i.e., Nursing, Physical Therapy, etc.)
Bachelor’s degree in Nursing
Health care coding certification strongly preferred
Five or more years’ progressively responsible experience in health care, a health insurance plan, or health care claims recovery environment required
Prior experience in a senior management position
Two or more years’ experience as a medical coder in a health care provider environment
Three or more years in management in a Managed Care Organization
Three or more years in a Medicaid or Medicare-centric organization (e.g., state Medicaid agency)
Two or more years in a health care fraud detection unit (e.g., Special Investigations Unit, Recovery Audit Contractor, Medicaid Fraud Control Unit)
Certification or Conditions of Employment:
If degree is in a field for which licensure is awarded, current licensure in Massachusetts or New Hampshire or license-eligible
Health care fraud investigator certification highly desirable.
Clinical coding certification highly desirable.
Pre-employment background check
Working Conditions and Physical Effort:
Regular and reliable attendance is an essential function of the position.
Work is normally performed in a typical interior/office work environment.
No or very limited physical effort required. No or very limited exposure to physical risk.
Occasional regional travel is required.