Manager Financial Investigations and Provider Review

Company :

Highmark Inc.

Job Description : 

JOB SUMMARY

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

• 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.

REQUIRED EDUCATION

Bachelor's Degree- Business, Finance, Healthcare Administration

Substitutions

6 years' minimum experience in auditing, consulting and/or fraud, waste and abuse (FWA)

PREFERRED EDUCATION

Business Administration

EXPERIENCE

Minimum:

• 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 management skills
• 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:

• 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

• 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

PREFERRED LICENSURE

Accredited Health Care Fraud Investigator (AHFI), Certified Fraud Examiner (CFE) or Certified Public Accountant

TRAVEL REQUIREMENT:  0%  - 25%
 

LANGUAGE REQUIREMENT (other than English):  
None

PHYSICAL, MENTAL DEMANDS AND WORKING CONDITIONS
Position Type:

Office-Based

Teaches/Trains others regularly  Rarely

Travels regularly from the office to various work sites or from site-to-site  Occasionally

Physical Work Site Required  No

Lifting: up to 10 pounds  Occasionally

Lifting: 10 to 25 pounds  Rarely

Lifting: 25 to 50 pounds  Never

ADDITIONAL INFORMATION

Changes Approved By:

Jeff Cypher

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

As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy. Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements. 

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.

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