Location: Cary, North Carolina
This position reports up through MetLife’s Fraud Waste & Abuse Center of Excellence (FWA CoE). Our mission is to eliminate Fraud, Waste & Abuse within the Global Health Claims Organization by providing expertise in the areas of analytics, analysis, reporting, and training. These factors will lead to improved detection, prevention and increased quality outcomes, while strengthening MetLife’s ability to deter insurance fraud, waste and abuse.
Role Value Proposition:
This position is primarily responsible for driving the day to day execution and strategic vision of the Governance, Strategy and Engagement Manager via the identification of global Fraud best practices, work flow/process improvements, compliance with all regulatory/legal requirements, and establishment and development of product analytics. This position will also help onboard and review trends, along with VR, of our single sourced vendor in an effort to help drive improvement in payment accuracy and quality. Collect, analyze, and utilize data to identify opportunities to improve Fraud Waste & Abuse capabilities both internally and externally.
Responsible for planning, designing, developing, and delivering (where appropriate) Fraud Waste & Abuse global best practices ensuring alignment across the globe within GHC.
Executing on, and ensuring a smooth adoption to, the end to end Fraud Waste & Abuse claims model within the US based GHC claims operations. This includes working with our Vendor Relations area to help identify trends and respond to claim operational complaints or concerns
Work with Manager to help evolve the current dashboard reporting to ensure that all global KPI’s are adhered to and consistent global reporting is easily accessible, informative and useful to the end user.
Evaluate, identify and implement continuous process improvements to increase efficiency and effectiveness of the Fraud Waste & Abuse Center of Excellence Operation to help ensure that delivery for our claims partners is exceeding expectations.
Continually partner with the appropriate lines of business, MetLife Data Science partners to review/update/refine the applicable analytical models and partner with single sourced vendor to ensure that all applicable regulatory and legal compliance Fraud Waste & Abuse aspects are adhered to and continually satisfied .
Essential Business Experience and Technical Skills:
5+ years of prior claims and/or claims investigative experience
Knowledge of the insurance industry and/or substantial work experience in the group health claims, fraud management for Disability, Dental, Long Term Care as well as Group Life, FEGLI and Total Control Account
Understanding health insurance laws and regulations related to disability, long term care, and dental
Bachelor’s Degree preferred
Strong organizational skills
Excellent verbal and written communication skills
Must have the ability to work independently and as a team member
Must have excellent computer skills
Project management skills
Extremely thorough and detail oriented
MetLife is a proud equal opportunity/affirmative action employer committed to attracting, retaining, and maximizing the performance of a diverse and inclusive workforce. It is MetLife's policy to ensure equal employment opportunity without discrimination or harassment based on race, color, religion, sex (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity or expression, age, disability, national origin, marital or domestic/civil partnership status, genetic information, citizenship status, uniformed service member or veteran status, or any other characteristic protected by law.
MetLife maintains a drug-free workplace.
For immediate consideration, click the Apply Now button. You will be directed to complete an on-line profile. Upon completion, you will receive an automated confirmation email verifying you have successfully applied to the job.
Requisition # 99199