Job Summary

Responsible for the strategic direction, planning, oversight, and operation of the Special Investigations ("SI") and Program Integrity ("PI") teams. Develops and directs the prevention, detection and investigation of anti-fraud, waste and abuse (FWA)program processes and oversight and coordination of all program integrity activities. Ensures all regulatory requirements are met including the completion of annual fraud plans and reports. Acts as a point of contact for collaboration with local, state and federal law enforcement and regulatory partners. Provides executive management with reimbursement or recovery recommendations based on PI team’s review of claims for appropriate coding, billed statistics, policies, industry standards and compliance with contractual, state, and federal regulation. Responsible for the management of the SIU and Program Integrity teams, their contracts and strategies and meeting the financial saving goals set by the enterprise.

Job Duties

• Provides leadership and strategic direction of Special Investigations and Program Integrity units spanning all lines of business.
• Ensures compliance with all regulators on anti-fraud and program integrity regulations.
• Presents to executive leadership the Privacy, Compliance and Program Integrity committee to report and communicate areas of non-compliance, risk, financial savings and potential fraud, waste or abuse
• Responsible for all PI & SI vendor relationships, including but not limited to, negotiating of contracts, adherence to key terms and ensuring contractual compliance.
• Leads teams through providing guidance, training, and counseling.
• Prepares and conducts performance appraisals to ensure team is high functioning and meeting both self and enterprise goals.
• Monitors workflow and production within the departments and prioritizes work accordingly.
• Coordinates interview process conducts interviews and initiates candidate selection.
• Partner with internal stakeholders to support product strategy and sales efforts with PI data.
• Collaborate with internal departments and maintain a dotted-line relationship with PI functions outside the direct organizational structure, including, but not limited to, Operations.
• Oversee the configuration, testing and maintenance of the SI and PI software, including upgrades, new release implementation, to ensure proper system set-up and operations for all activity.
• Oversee all external and internal Fraud, Waste and Abuse and Program Integrity audits.
• Responsible for Key Performance Indicators including claim edit and claim audit savings, dollars at risk, overpayment recoveries, referrals, as well as department return on Investment.
• Develops and executes a multi-year PI strategy aligned with financial goals set by the enterprise.
• Manages budget and financial performance for PI and SI.

Work is typically performed in an office environment. Accountable for satisfying all job specific obligations and complying with all organization policies and procedures. The specific statements in this profile are not intended to be all-inclusive. They represent typical elements considered necessary to successfully perform the job.

#LI-REMOTE

Position Details

Education

Master's Degree- (Required), Master's Degree-Law (Preferred)

Experience

Minimum of 10 years-Health Insurance/Managed Care (Required), Minimum of 5 years-Managerial/Supervisory (Required)

Certification(s) and License(s)

OUR PURPOSE & VALUES: Everything we do is about caring for our patients, our members, our students, our Geisinger family and our communities. KINDNESS: We strive to treat everyone as we would hope to be treated ourselves. EXCELLENCE: We treasure colleagues who humbly strive for excellence. LEARNING: We share our knowledge with the best and brightest to better prepare the caregivers for tomorrow. INNOVATION: We constantly seek new and better ways to care for our patients, our members, our community, and the nation. SAFETY: We provide a safe environment for our patients and members and the Geisinger family We offer healthcare benefits for full time and part time positions from day one, including vision, dental and domestic partners. Perhaps just as important, from senior management on down, we encourage an atmosphere of collaboration, cooperation and collegiality. We know that a diverse workforce with unique experiences and backgrounds makes our team stronger. Our patients, members and community come from a wide variety of backgrounds, and it takes a diverse workforce to make better health easier for all. We are proud to be an affirmative action, equal opportunity employer and all qualified applicants will receive consideration for employment regardless to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or status as a protected veteran.

We are an Affirmative Action, Equal Opportunity Employer Women and Minorities are Encouraged to Apply. All qualified applicants will receive consideration for employment and will not be discriminated against on the basis of disability or their protected veteran status.

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