Fraud, Waste, and Abuse Investigations Manager

Exemption Status:
United States of America (Exempt)

$85,356 - $115,232 - $145,107

"Pay scale information is not necessarily reflective of actual compensation that may be earned, nor a promise of any specific pay for any selected candidate or employee, which is always dependent on actual experience, education, qualifications, and other factors. A full review of our comprehensive pay and benefits will be discussed at the offer stage with the selected candidate."

This position is not eligible for Sponsorship.

MedImpact Healthcare Systems, Inc. is looking for extraordinary people to join our team!

Why join MedImpact? Because our success is dependent on you; innovative professionals with top notch skills who thrive on opportunity, high performance, and teamwork. We look for individuals who want to work on a team that cares about making a difference in the value of healthcare.

At MedImpact, we deliver leading edge pharmaceutical and technology related solutions that dramatically improve the value of health care. We provide superior outcomes to those we serve through innovative products, systems, and services that provide transparency and promote choice in decision making. Our vision is to set the standard in providing solutions that optimize satisfaction, service, cost, and quality in the healthcare industry. We are the premier Pharmacy Benefits Management solution!

Job Description

Summary:

The Fraud, Waste, and Abuse Investigations Manager handles the operational activities related to Pharmacy Compliance, FWA. This will require close partnership and collaboration with a cross-functional group of leaders. It will be essential to have outstanding program management skills, as well as exceptional interpersonal, communication and relationship building skills.

This position reports to the Director, Strategic Account Management and their primary role is performing consultations with related parties to complete comprehensive investigations and improve surveillance of FWA. The FWA Investigations Manager will document the intervention and communicate essential information to the client team for dissemination to clients. This position will be the point of contact for client SIU's and Pharmacy Audit teams.

Primary Responsibilities

Responsible for fraud and abuse detection activities for the state defined PBA Programs, including the Fraud and Abuse Compliance Plan. Will be responsible for day-to-day Provider investigation-related inquiries.

Utilizes prescription and medical claim data to generate clinical recommendations according to "Global" Drug Utilization Review program protocols. Provides clinical recommendations pertaining to, but not limited to, gaps in care, high risk medications, compliance and adherence, drug interactions, therapeutic substitution, and generic substitution. Utilizes client formulary information to guide appropriate medication recommendations. Keep current with new and emerging clinical trends. Provides active participation in departmental meetings to improve clinical programs and enhance processes. Share clinical information and department procedure protocols during client site visits. Assists the FWA Team with new clinical programs and system enhancements. Follow all policies and procedures related to job clinical support as needed for special projects and other duties as assigned by the Director, Compliance, FWA. Perform other duties as assigned to meet departmental objectives.

Under the guidance of the FWA Management, this position is responsible for the accurate and thorough clinical investigation of potential external fraud and abuse involving commercial and government lines of business. The scope of accountability includes investigating and remediating allegations of fraud, waste and abuse involving providers. Primary activities include substantiating referrals, case research and planning, conducting onsite or desk audits, clinical reviews of medical records to ensure correct billing of services and appropriateness of care, interviewing potential witnesses, developing corrective action plans, developing correspondence to impacted parties, managing disputes and collaborating with law enforcement and regulatory agencies. Additional accountability includes cooperation of fraud, waste and abuse efforts with external business partners.

Essential Duties and Responsibilities include the following. Other duties may be assigned.

Reviews medical and pharmacy records, researches and investigates complex cases for the purpose of detecting fraud both internal and external involving submission/payment of claims and identifies FWA issues for follow-up. The FWA Investigation Manager interprets a variety of documents including, but not limited to client contracts, group benefit structures, Workplan Policies and Procedures, governmental policies as well as diverse regulatory and legal requirements.

In conjunction with the FWA Clinical Pharmacist, thoroughly researches an allegation or issue and develops sources of information to create a plan of action, accumulating sufficient detailed evidence including statements, documents, records, exhibits, and photographs for the successful adjudication of identified FWA cases or audit results.

• Makes sound rational clinical judgments and decisions in the progression of their cases, keeping management routinely apprised of the progress.

Requests and analyzes data in order to identify fraudulent billing patterns.

• Solves problems using sound professional judgment to determine the appropriate course of action and independently follows through, when necessary.

Provides routine interaction, referrals, and coordination with Medicaid, CMS, NICB, MEDIC, local, state and federal law enforcement, and regulatory licensing boards.

Monitors the regulatory interactions with our network of providers, prescribers, and members.

• Functions independently with appropriate oversight in sensitive situations.

• Evaluates situations accurately and interacts frequently with managers, supervisors, and legal to ensure complex issues are addressed appropriately.

Prepares comprehensive Reports of Findings and prepares cases for potential prosecution and civil settlement by documenting findings in a clear and concise manner.

May be required to review files and testify in court or the Credentialing Adjudication Committee, as needed, in matters regarding litigation/adjudication related to their reviews.

• Manages cases as assigned, prioritizing case load as appropriate. Maintains case logs, prepares records and regular status reports.

Interacts frequently with providers of health care, often under adverse conditions due to potential discovery of fraud, waste or abuse. The incumbent shall discuss sensitive material in a professional, fair and accurate manner.

• Acts as primary point of contact with law enforcement for assigned cases in conjunction with the FWA Investigator.

Interprets various data analyses and information gathered in the detection process, determines what information to analyze further and what trends or issues to report to others.

Prepares recommendations on preventive/corrective measures for the deterrent of future fraud.

• Supports other FWA personnel and analysts with their cases by providing medical information/expertise and as necessary, performs clinical reviews of medical records for other FWA cases.

Contributes to development of medical procedural guidelines, protocols, and employee training. The incumbent shall remain knowledgeable about State and Federal laws involving health care fraud.

• Consistently demonstrates high standards of integrity by supporting the Medlmpact's Mission and Values and adhering to the Corporate Code of Conduct.

Maintains high regard for member privacy in accordance with the corporate and regulatory privacy rules, regulations, policies and procedures.

Interfaces appropriately with many different provider types, attorneys, external agencies, other departments

Discerns when to suggest deviations from standard practices based on tangible and intangible factors.

• Offers process improvement suggestions and participates in the solutions of more complex issues/activities.

Mentors staff and assists with training and coaching, whenever necessary.

• Serves as a subject matter expert and liaison, representing non-clinical staff in discussions with clients or other departments.
• Serves as an internal auditor/peer reviewer for new investigative staff, as needed.

Provides back up for Supervisor/Manager, whenever necessary.

• Provides day-to-day oversight of department, including developing and administering policies, business processes and quality standards, and assist in developing and managing a departmental policies and procedures.
• Establishes procedures to ensure compliance with state and federal FWA and FWA contracts and agreements.
• Ensures that deliverables meet the quality levels expected by internal departments and external clients;

• Responsible for assisting in coordinating all contracting efforts with outside vendors that support provider audits, credentialing and FWA.

Responsible for defining standards in support of the department-wide goals, to ensure consistent execution of all related projects by multiple teams, including: planning, execution, effectiveness, standards, escalations, and how to manage unique investigations.

• Oversee operations between the BA/IT, Pharmacy Compliance, FWA and FIST (EWA !mpact §.IU Ieam) to ensure projects are delivered on schedule and meet state and/or federal regulations.

Supervisory Responsibilities

No supervisory responsibilities

Client Responsibilities

This is an internal and external client facing position that requires excellent customer service skills and interpersonal communication skills (listening/verbal/written). One must be able to; respond promptly to client needs; solicit client feedback to improve service; respond to requests for service and assistance from clients; meet commitments to clients; and manage difficult or emotional client situations.

Qualifications

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Work Location

This position must be located in Tennessee. Must provide adequate support to internal clients; be available for regular interactions and coordination of work with other employees, colleagues, clients, or vendors; as well as be available to facilitate effective decisions through collaboration with stakeholders

Education and/or Experience

Bachelors' degree from an accredited college or university required, advance degree, from an accredited college or university, highly desired. 4 - 6+ years' experience working in a lead investigative role. Proven experience in project development or management. Prior experience in Asset Protection/Investigations setting with compliance exposure preferred.

Computer Skills

Strong proficiency with personal computers and MS Office products to include intermediate to advanced working knowledge of MS; Word, Excel, Access and Outlook. Familiarity with relational database systems required. Knowledge of SQL software front ends such as MedOptimize required. Strong aptitude to learn and adapt to new programs. Continuous improvement of and training in data mining skills.

Certificates, Licenses, Registrations

None Required

Other Skills and Abilities

• Good working knowledge of research development, methodologies, reporting, analysis, and publishing
• Ability to balance a high volume of work & variety of tasks and prioritize urgent issues
• Detail oriented with a high degree of accuracy and time management
• Strong passion for providing service to the customer as defined as our clients, members, and other departments
• Self-starter with the ability to work independently and as part of our team
• Ability to influence others, lead workgroups, and coordinate service requests throughout the organization
• Ability to gather, document, and communicate business requirements and client specifications
• Ability to understand and interpret contract language and negotiate favorable contract terms
• Deep knowledge of the health benefits arena, preferably in pharmacy benefits management, Medicare Part D, Medicaid and Health Exchanges.
• Superior ability to determine State and Federal fraudulent activity and compile necessary documentation for prosecution presentation. Explain and interpret these findings to law enforcement authorities in a cognizant manner.
• Must remain current and cognizant of medical and pharmacy standards of care and practices in the community.

Reasoning Ability

Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.
Mathematical Skills

Ability to work with mathematical concepts such as probability and statistical inference, and fundamentals of plane and solid geometry and trigonometry. The incumbent will have the ability to apply concepts such as fractions, percentages, ratios, integrals, and proportions to practical situations.
Language Skills

Ability to read, analyze, and interpret common scientific and technical journals, financial reports, and legal documents. Ability to respond to common inquiries or complaints from customers, regulatory agencies, or members of the business community. Ability to write speeches and articles for publication that conform to prescribed style and format. Ability to effectively present information to top management, public groups, and/or boards of directors.

Competencies

To perform the job successfully, an individual should demonstrate the following competencies:

• Adaptability - Adjusts quickly to evolving situations by integrating new information, remaining flexible, recognizing and implementing necessary changes and taking advantage of opportunities presented by new developments.

• Relationship Building and Networking - Maintains a network of diverse contacts both inside and outside of the organization, initiates productive collaborations with people in all parts of the organization, makes regular efforts to get to know new people, reaches out for help when appropriate and is available to help others when approached.

• Communication -Expresses self clearly and effectively in face-to-face interactions, presentations and written documents, and employs active listening skills to ensure productive interactions.

• Customer/Client Focus- Shows solid grasp of characteristics and needs of both internal and external customers, interacts directly with customers, takes personal responsibility to ensure that customers' concerns and needs are fully understood and addressed, and follows up to ensure customer satisfaction.

• Initiative - Proactively gathers and analyzes information, assesses situations and identifies challenges and opportunities, sees what needs to be done and takes appropriate action.

• Integrity - Builds trust with other people, tells the truth directly, aligns actions with stated values, takes responsibility for failures when needed and assigns credit appropriately

• Interpersonal Effectiveness - Demonstrates good people skills by showing a commitment to teamwork, resolving conflicts effectively and with respect for others' viewpoints, respecting differences and building strong relationships and networks.

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this Job, the employee is regularly required to sit and talk or hear. The employee is frequently required to use hands to finger, handle, or feel and reach with hands and arms. The employee is occasionally required to stand and walk. The employee must occasionally lift and/or move up to 10 pounds. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus.

Work Environment

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this Job, the employee is occasionally exposed to moving mechanical parts; fumes or airborne particles; toxic or caustic chemicals and risk of electrical shock. The noise level in the work environment is usually moderate.

Working Hours

This is an exempt level position requiring one to work the hours needed to get the job done. Therefore one must have the flexibility to work beyond traditional hours and be able to work nights, weekends or on holidays as required. This may be changed from time to time to meet the needs of the business. Typical core business hours are Monday through Friday from 8:00am to 5:00pm.

Travel - This position will require occasional domestic travel.

The Perks:

• Medical / Dental / Vision / Wellness Programs
• Paid Time Off / Company Paid Holidays
• Incentive Compensation
• 401K with Company match
• Life and Disability Insurance
• Tuition Reimbursement
• Employee Referral Bonus

To explore all that MedImpact has to offer, and the greatness you can bring to our teams, please submit your resume to

MedImpact, is a privately-held pharmacy benefit manager (PBM) headquartered in San Diego,
California. Our solutions and services positively influence healthcare outcomes and expenditures, improving the position of our clients in the market. MedImpact offers high-value solutions to payers, providers and consumers of healthcare in the U.S. and foreign markets.

Equal Opportunity Employer, Male/Female/Disabilities/Veterans
OSHA/ADA:

To perform this job successfully, the successful candidate must be able to perform each essential duty satisfactorily. The requirements listed are representative of the knowledge, skill, and/or ability required.
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Disclaimer:

The above
statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified.