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) related to the company’s provider spending. The incumbent functions 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. The incumbent is responsible for the overall leadership of the teams assigned, including prioritizing work, developing appropriate action plans and managing audit referrals, as necessary, assigning work internally and to recovery vendors and executing administrative/budget aspects, as appropriate. Responsible for overall people strategy, including the recruitment, performance management and retention, of individuals within assigned teams.
Provide strategic leadership to the entire department regarding claims audits/investigations of various hospital/facility organizations and/or through special investigations.
Work with senior management to define recovery opportunities based on spending and risk by provider type.
Develop 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.
Actively communicate 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.
Serve in a variety of capacities in representing the department.
Manage vendor relationships
Assist in identifying new/modified reimbursement and medical policies
Serve as liaison for all the company’s customers as it relates to the company’s fraud, waste and abuse program and fraud awareness trainings
Participate on Medical Review Committee (MRC), including being key liaison to external professionals serving on the MRC; preparing and presenting provider/network appeal cases; and/or providing technical expertise in evaluating/resolving cases
Interact with external legal counsel regarding case inquiries
Collaborate with other business units
Deliver daily guidance to management and team leads regarding case investigation activities including the development of detailed strategies for each case.
Ensure staff and management are aware of all regulatory and customer requirements regarding the department’s scope of activities and ensure adherence to these requirements.
Oversee the development of appropriate technology tools.
Evaluate and implement innovative methods to identify fraud, waste and abuse including cutting edge statistical analysis tools that detect overutilization.
Ensure that the department communicates with external parties to stay informed regarding current FWA schemes and potential investigation approaches to combat schemes.
Ensure that employees at all levels including managers, team leaders and staff have a thorough understanding of audit and compliance and strategies.
Manage employee performance to ensure a culture of continuous improvement by all employees.
Establish and maintain development plans for all employees.
Other duties as assigned or requested.
QUALIFICATIONS
Minimum
Bachelor’s Degree or related experience in lieu of a degree
10 years of experience in the health care industry, with minimum 5 years focus on hospital/facility reimbursement, provider contracting or post payment utilization environment
5 years managerial experience
For operations, 3 years exposure to claims analysis/investigation activity
Preferred
Certified Public Accountant (CPA)
5 years of experience in provider claim review and recoveries
10 years of experience in review of payment or hospital reimbursement
Significant experience in positions requiring the monitoring and measurement of financial impact of activities
Skills
Proven leadership skills – ability to motivate others to quickly achieve results in a matrixed environment
Uses knowledge of industry and market trends to develop and champion long-term strategies
Demonstrates the ability to effectively persuade others to listen, commit, and act on a new approach
Self-confident with an ability to accept and respond to challenges in a positive manner
Strong and effective verbal and written communication skills
Effectively presents complex topics in a concise manner to audiences at various levels and in various sizes
Broad understanding of business issues, metrics, organizational linkages and customer value
Successful experience in achieving results through people in a complex environment
Strong organizational and analytical skills in addition to project leadership and management skills
Knowledge of health care claims processing systems
Knowledge of 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 Comprehensive knowledge of legal and investigative procedures used in the detection and successful resolution of health care fraud/abuse cases
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