Fraud, Waste, and Abuse Investigations Manager

Fraud, Waste, and Abuse Investigations Manager

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.

• 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 Impact §.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.

Other Skills and Abilities

• Good