Director Financial Investigations & Provider Review

Company :

Highmark Inc.

Job Description : 

JOB SUMMARY

This job is responsible for the execution of the strategic plan of the Financial Investigations & Provider Review (FIPR) organization.  The strategic plan focuses on the detection and investigation of fraud, waste and abuse (FWA) and recoupment of related overpayments associated with the company’s provider spending.  The incumbent will function as a champion and driving force in the development of hospital/facility reimbursement related strategies to audit, educate, and secure financial recoveries when necessary, and/or to develop action plans for cases referred to law enforcement, if applicable.

ESSENTIAL RESPONSIBILITIES

• Performs management responsibilities to include, but are not limited to: involved in hiring and termination decisions, coaching and development, rewards and recognition, performance management and staff productivity.
• Plans, organizes, staffs, directs and controls the day-to-day operations of the department; develops and implements policies and programs as necessary; may have budgetary responsibility and authority.
• Provides daily direction and oversight to management and team leads regarding case investigation activities including the development of detailed strategies for each case.  Ensures management and staff are aware of all regulatory and customer requirements regarding the department's scope of activities and ensures adherence to all requirements.  Provides executive review and sign-off for cases involving fraud, waste and abuse (FWA) at the provider and/or facility level.
• Provides strategic vision, development, planning, execution and leadership to the department regarding claims audits and investigations of various hospital and facility organizations and/or through special investigations by (a) working with senior management to define recovery opportunities based on spending and risk by provider type, (b) developing action plans and priorities for various recovery opportunities with a focus on the continual increase in financial impact generated by audits, vendor audits and analysis activities, (c) actively communicating with management from various departments regarding impact on provider relations and reimbursement, and (d) providing direction on and/or participating in department projects, process improvements, efficiency initiatives, system enhancements and policy and procedures to improve workflows. Serves in a variety of capacities in representing the department, including but not limited to such activities as: (a) managing matrix organizational and/or vendor relationships, (b) identifying new and/or modified reimbursement and medical policies, (c) serving as liaison for all company's customers as it relates to the company's fraud, waste and abuse (FWA) programs and fraud awareness training, (d) participates on Medical Review Committee (MRC), including being a key liaison to external professionals serving on the MRC; prepares and presents provider / network appeal cases; and/or providing technical expertise in evaluating and resolving cases, (e) communicating and partnering with external legal counsel regarding case inquiries, and (f) collaborating with other business units.
• Ensures that department personnel, including managers, team leaders and staff have a thorough understanding of audit, compliance and strategies imperative for department success.  Ensures a culture of continuous improvement by all staff.
• Oversees the development of appropriate technology tools. Evaluates and implements innovative methods to identify fraud, waste and abuse (FWA), including cutting edge statistical analysis tools that detect over-utilization. Ensures that the department personnel communicates with external parties to stay informed regarding current fraud, waste & abuse (FWA) schemes and potential investigation approaches to detect, mitigate and resolve schemes.
• Other duties as assigned or requested.

EDUCATION

Required

• Bachelor's Degree in Business, Finance, Healthcare Administration

Substitutions

• 6 years experience in healthcare, provider reimbursement, providing contracting, fraud, waste, and abuse investigations, or related field.

PREFERRED EDUCATION

• Master's in Business Administration

EXPERIENCE

Required

• 10 years in the Healthcare Industry
• 5 years of:
  • focusing on hospital administration, hospital and/or facility reimbursement, provider contracting, post payment utilization environment and/or consulting experience OR 
  • identifying and negotiating Professional Provider fraud, waste and abuse (FWA) settlements and/or healthcare audit consulting experience with