The ideal candidate will possess a strong understanding of healthcare regulations and compliance requirements. The primary responsibility of this role is to ensure adherence to regulatory guidelines, detect and prevent fraud, waste, and abuse, and implement strategies to mitigate risks effectively.
Duties & Responsibilities
FWA Monitoring and Analysis:
Conduct regular reviews and audits of transactions, claims, and provider/member activities to identify potential instances of fraud, waste, or abuse
Analyze data trends and patterns to detect irregularities or suspicious activities
Utilize analytical tools and methodologies to assess compliance with regulatory requirements and organizational policies
Investigation and Reporting:
Performs data mining and analyses to detect aberrancies/outliers in claims and data to proactively seek out and report FWA
Conduct thorough investigations into suspected cases of fraud, waste, or abuse, including gathering evidence, interviewing stakeholders, and documenting findings
Prepare detailed reports documenting investigation outcomes, including recommendations for corrective action and risk mitigation strategies
Collaborate with relevant departments, such as legal, compliance, and risk management, to address compliance concerns and implement remedial actions
Prepares any Health Plan Compliance reports related to FWA
Training and Education:
Develop and deliver training programs and educational materials to enhance awareness of compliance requirements and FWA prevention strategies among staff and providers
Stay updated on emerging trends, technologies, and regulatory changes in the healthcare industry
Promotes and contributes to a positive, problem-solving environment
Performs other related duties as assigned by management
Requirements
Associate degree or equivalent preferred
Required to have 3+ years of experience working for a Managed Care Organization, specifically with the transportation benefit, or for a transportation broker operating in multiple states
Proficient in Microsoft based applications
Excellent written and oral communication skills
Versatility, flexibility, and a willingness to work within constantly changing priorities with enthusiasm
Acute attention to detail
Ability to deal effectively with a variety of individuals at all organizational levels
Ability to communicate professionally and effectively in person, on the phone, electronically, or through other means to individuals and groups
Good judgment with the ability to make timely and sound decisions
Professional appearance and demeanor
Ability to effectively present information and respond to questions
Job Type: Full-time
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Seniority level
Entry level
Employment type
Full-time
Job function
Finance and Sales
Industries
Internet Publishing
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