- Leads team of Sr. Investigators, Nurses, Supervisor, Analysts and Administrative support in the planning and development of health care fraud investigations.
- Develops and oversees a system for uniform handling of investigations.
- Coordinates department's final referral product with government customer and other Federal agencies
- Prioritizes workload, coordinates functions between company departments, and processes issues to completion
- Develops and ensures compliance with state and federal regulations where appropriate; enforces contractual requirements
- Identifies potential areas of fraud vulnerability and risk, develops and implements corrective action plans for resolution of problematic issues and provides general guidance on how to avoid or deal with similar situations in the future
- Provides reports and assistance to management as requested, drafts position papers as requested
- Represents Company in settlement negotiations and civil/criminal legal proceedings
- Identifies, changes, implements and maintains departmental policy and procedures
- Responsible for recruiting, interviewing, hiring, and training department staff.
- Prioritizes workload, conducts performance reviews and takes disciplinary action as necessary.
- Conducts regular case reviews to assess quality of investigations
- Prepares, manages and accurately forecasts assigned cost center
- Other duties as assignedEducation/Experience: Bachelor's Degree in Criminal Justice or related. Five years experience in conducting and reviewing health care fraud investigations. Three years management experience. Experience in the health insurance industry and/or experience with the TRICARE program.
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Manager, Program Integrity - Long Island City, United States - Corporate
Description
You could be the one who changes everything for our 26 million members. Centene is transforming the health of our communities, one person at a time. As a diversified, national organization, you'll have access to competitive benefits including a fresh perspective on workplace flexibility.Position Purpose:
The Manger of Program Integrity supervises and directs a field of Investigators, Nurses, Supervisors, Research Analysts and other administrative functions in the identification, prevention and investigation of theft, embezzlement, healthcare fraud and abuse.
The Manager of Program Integrity ensures all government and/or contractual requirements are met regarding the individual requirements for the TRICARE Program or any other company contract.
The manager reviews case documentation, medical record audits, claims system editing, claims processing guidelines, and interprets medical policy requirements against the requirements set forth in the TRICARE Operations Manual, health care fraud statues and other documentation.
This position is responsible for coordinating cases of potential fraud, abuse, theft, and embezzlement with State, and Federal agencies through case referrals and criminal or civil litigation by educating these agencies on the individual case investigational findings, case evidence, claims interpretation, medical record review, medical policy interpretation, statistically valid audit procedures, governmental or commercial claims payment policies and company functions outside of the department (i.e. provider contracting, Quality Management, provider education, etc.)- Develops an effective and strategic plan and program for the prevention of fraud against the company that minimizes the risk of lossLicense/Certification:
Accredited Healthcare Fraud Investigator (AHFI) preferred
Our Comprehensive Benefits Package:
Flexible work solutions including remote options, hybrid work schedules and dress flexibility, Competitive pay, Paid time off including holidays, Health insurance coverage for you and your dependents, 401(k) and stock purchase plans, Tuition reimbursement and best-in-class training and development.
Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different.
All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.
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