Behavioral Health - Case Manager I providing telephonic case management for members with behavioral health needs. Responsible for assessing member needs and developing care plans within the scope of licensure.
About the role
- Manager, Program Integrity managing fraud, waste, and abuse investigations in healthcare. Leading investigative teams and ensuring compliance with state and federal regulations while driving innovative approaches.
Responsibilities
- Responsible for managing Program Integrity requirements including allegation intake, report analysis, triage, investigation, correction and reporting of fraud, waste and abuse
- Manage all efforts of the investigative team focusing on timely investigations, root cause identification, state and federal law enforcement collaboration
- Ensure employees meet all state and federal contract requirements
- Drive and encourage innovative approaches to increase department effectiveness and efficiency
- Lead the Investigative team to resolution including corrective action plans, terminations, Fair Hearings, recoveries, negotiations, mediation, and litigation
- Mentor employees on effective investigative case presentation and development
- Drive fraud identification through information sharing
- Participate in strategic planning and implement action plans
- Speak at national conferences on investigative efforts and fraud trends
Requirements
- Bachelor of Science/Arts Degree in Criminal Justice, Medical/Health Care Field or related industry or equivalent years of relevant work experience
- Minimum of six to eight (6-8) years of investigative or health care experience
- Extensive experience in health care, legal, auditing, claims and/or investigative services
- Leadership/supervisory experience preferred
- Solid understanding of claims processing preferred
- Intermediate to advanced proficiency level of computer skills, including Microsoft Outlook, Word, Excel, Access, and Power Point
- Significant knowledge of government program compliance requirements – Medicare, Medicaid, Affordable Care Act (ACA), etc. preferred
- Significant knowledge of medical insurance and/or state regulatory requirements
- Certified Fraud Examiner (CFE), Certifications through America’s Health Insurance Plans (AHIP), Healthcare Anti-Fraud Association (HCAFA) and/or Managed Healthcare Professional (MHP), Accredited Health Care Fraud Investigator (AHFI), and/or Certified Professional Coder (CPC) are preferred
Benefits
- Health insurance
- Comprehensive total rewards package
- Bonuses tied to company and individual performance
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