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   Current UPMC employees must apply in HR Direct

Manager, Fraud Waste and Abuse

  • Job ID: 728006743
  • Status: Full-Time
  • Regular/Temporary: Regular
  • Hours:
  • Shift: Day Job
  • Facility: UPMC Health Plan
  • Department: Fraud, Waste & Abuse
  • Location: , Work From Home Work From Home
  • Union Position: No
  • Salary Range: $30.17 to $50.94 / hour

Description

Shape the world of health care by joining UPMC! As a leader in the industry, we are committed to enhancing the lives of all who are a part of our community. Without our employees, we would not be able to innovate health care for our patients and health plan members. From hospitals to our corporate office, all UPMC employees impact our mission of creating life changing medicine. To continue our tradition of excellence, we are in search for a Manager of Fraud Waste and Abuse to join this community as well.


The Manager is responsible for the review, management, and staff assignment related to fraud and abuse referrals and associated investigations. The Manager is responsible for supervision over and maintenance of the Fraud, Waste and Abuse databases, compliance matrices, and other unit reporting. The Manger leads internal unit meetings, and represents the Special Investigations Unit at other interdepartmental meetings and at meetings external to the Health Plan. The Manager directs and monitors communication between the Health Plan and the Bureau of Program Integrity/DPW and CMS MEDICS, as well as Health Plan Compliance and Pharmacy personnel. The Manager is also responsible for the unit providing trending, analysis and reporting of referrals and investigative data and the compilation of reports from the data warehouse utilizing identified software tools. This Manager is responsible for creation and revision of the Special Investigation Unit's policies and procedures, and serves as a process expert for fraud, waste and abuse investigations and associated financial recoveries.

Responsibilities:

 

  • Manage the detection and review of potentially fraudulent activity by any parties against UPMC Health Plan, and implements the most effective and efficient method of investigation for each individual case.
  • Ensure that all SIU turn-around-times and quality measurements are met.
  • Evaluate the work of SIU personnel and completes all required performance review documentation.
  • Perform on-site visits to providers when appropriate.
  • Director, the Health Plan Legal Services and Compliance personnel.
  • Manage training for unit personnel in corporate and unit procedures and investigative techniques.
  • Manage communication with the IFPA, PID, DPW, CMS, local, county, state, and federal law enforcement, and all Regulatory oversight agencies, as well as, key internal contacts.
  • Ensure that all unit goals and objective are met in a timely, efficient fashion.
  • Manage the Fraud and Abuse Training Program for all UPMC Health Plan personnel.
  • Perform reviews of case files for sufficiency of content and documentation.
  • Represent the SIU in a court of law as required when approved by the department director, the Health Plan Legal Services and Compliance.
  • Coordinate settlements, subrogation, reimbursement, and restitution for UPMC Health Plan Inc. as directed by the department
  • Represent the Special Investigations Unit (SIU) at internal and external meetings.
  • Develop and maintains the UPMC Health Plan's Anti-Fraud and Abuse / SIU Plan.
  • Develop and maintains the Fraud and Abuse / SIU policy and procedures, and insures that all actions and investigations conform to the SIU policy and procedures.
  • Manage the development and oversight of the SIU budget.

 

Qualifications

  • Bachelor's degree in a job related field.
  • Minimum of 5 years of experience in Insurance Fraud, Loss Prevention, Law Enforcement or Risk Management.
  • Leadership/supervisory experience required.
  • Formalized training / experience in Health Care Insurance Fraud preferred.
  • Excellent oral and written communication skills are required.
  • Strong leadership skills and abilities, strong independent decision making skills are a must.
  • Expert process and project management, negotiation, and analytical skills are required.
  • Must possess excellent organizational, interpersonal, and conflict management skills.
  • Candidate must be proficient in Microsoft Access, Word, and Excel.
  • Knowledge of HMO, PPO, POS, Medicare, Medicaid productsand ICD-9, CPT-4 coding preferred.


Licensure, Certifications, and Clearances:
Training from accredited program with a concentration in Insurance Fraud/Financial Investigative Techniques or Certified Professional Coder preferred.


UPMC is an Equal Opportunity Employer/Disability/Veteran

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   Current UPMC employees must apply in HR Direct