AVP, Payment Integrity

UPMC Health Plan is seeking an experienced, motivated, senior professional from the Healthcare Insurance space who is ready to take on an exciting, rewarding role at a market-leading, quickly growing Health Plan as an Associate Vice President (AVP) of Payment Integrity!

The Associate Vice President (AVP), Payment Integrity reports to the Senior Vice President, Chief Risk, Compliance & Ethics Officer and strategically and operationally leads the development, implementation, and management of a robust and effective set of Fraud, Waste & Abuse (FWA) and Special Investigations Unit (SIU) for UPMC’s large and growing Insurance Services Division. Overseeing and working with each relevant team’s functional leader, this position strategically facilitates, monitors, investigates and ensures compliance with all relevant and applicable laws, regulations, contractual agreements, standards, and requirements in a manner that continually supports the business and operational areas across the wide array of highly diversified products and lines of business at UPMC Insurance Services. The role also reviews, tests, validates, and ensures that our payment integrity-related processes, controls, practices, and activities are soundly and effectively operating in a manner that strengthens and facilitates our business, financial and operational objectives.

The ideal incumbent of the role would be local to Pittsburgh, however others in Pennsylvania or surrounding areas who bring an expansive skillset may be considered.

Responsibilities:

• Monitors and ensures compliance with all relevant and applicable laws, regulations, contractual requirements, standards and practices for all relevant stakeholders, both internal and external to the organization (including all regulatory and law enforcement entities).
• Develops, assesses, and adapts clear and effective FWA policies, procedures, training, communications and awareness materials, campaigns, controls, and initiatives to ensure clear and consistent preventive, detective, investigative and remedial measures, understanding and practices throughout internal and external operations (including third parties).
• Develops, assesses, and adapts clear and effective FWA monitoring, testing, reporting, auditing and sampling protocols, controls and channels to ensure the proper and timely detection of relevant issues.
• Develops, assesses and adapts clear and effective remediation and corrective action initiatives, protocols and controls to ensure proper and timely improvements and compliance.
• Keeps abreast of changing industry requirements and regulations, including all relevant laws, rules, contractual agreements, industry standards, company practices and initiatives.
• Provides clear and effective reports to the relevant business, functional and operational areas, as well as other internal/external stakeholders, regarding new or prospective laws, regulations, contractual requirements, industry standards and best practices.
• Oversees and directs annual and ongoing FWA training, as appropriate or warranted, to UPMC Insurance Services Division staff and applicable parties, both internal and external to the organization.
• Oversees and directs regular gap analyses, risk assessments and program effectiveness assessments for the different FWA programs and functions, including all relevant and applicable activities.
• Develops annual FWA, Special Investigations Unit (SIU), clinical auditing, focused audit plans, based upon regular risk assessments and ongoing, data- and metrics-driven analyses, proactively identifying and utilizing the most recent and relevant industry/regulatory trends.
• Leads and oversees the facilitation, monitoring and tracking of all audits, whether internal or external, across the broad and diversified Insurance Services enterprise, including relevant responses, corrective actions and management action plans.
• Leads and oversees the contracting, implementation and management of various third-party products and services, automated tools and otherwise, to facilitate and ensure robust and effective FWA activities.
• This includes fraud detection software, data mining and analytics tools, subrogation vendors, and other such service providers. Coordinates and oversees settlements, subrogation, reimbursement, and restitution for UPMC Insurance Services, in conjunction with relevant personnel.
• Ensures strategic and operational partnership and collaboration with the business and operational areas, as well as with sibling Governance, Risk & Compliance (GRC) teams to leverage cross-departmental synergy and efficiencies.
• Develops, chairs, and leads FWA committees and working groups, ensuring that all relevant issues and data are appropriately and timely communicated, understood, aligned upon and actioned.
• Owns and performs strategic planning, goal planning, budget planning and management, performance review, professional development, and all other executive-level managerial functions for all FWA Programs, functions and teams.
• Represents UPMC Insurance Services Division with all relevant regulatory agencies, law enforcement authorities, customers, stakeholders, and entities regarding FWA reviews, inquiries, investigations and/or requests for information.
• Represents the organization in a court of law or other relevant law enforcement proceedings, as appropriate or warranted.
• Develops and reports clear and relevant FWA Program metrics and dashboards to measure Program effectiveness and to proactively identify relevant trends and patterns across all Insurance Services lines of business.
• Develops and delivers clear, effective, and timely reports and updates for senior management and/or the Board regarding the FWA Program effectiveness, initiatives and issues, including all relevant metrics, dashboards and information, across all Insurance Services lines of business.
• Performs other duties as assigned.
• Effectively lives, models, communicates, and supports the values of UPMC and UPMC Health Plan.
• Performs in accordance with UPMC System-wide competencies and behaviors.