Senior Director Program Integrity and Special Investigations Unit, Geisinger Health Plan

Location:

Work from home (Pennsylvania)

Shift:

Days (United States of America)

Scheduled Weekly Hours:

40

Worker Type:

Regular

Exemption Status:

Yes

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 <