Manager - Fraud Waste and Abuse Pre-Pay Triage

The Manager- Fraud, Waste, and Abuse (FWA) Pre-Pay Triage is responsible for the development and execution of end-to-end strategies and processes in support of the organization’s effort to reduce unnecessary medical spend and make healthcare more affordable for everyone. The primary responsibility will be to drive the triage team’s performance with a focus on process improvement and staff development.

Responsibilities

• Lead a team of individuals responsible for screening high risk claims for signs of fraud, waste, or abuse.
• Optimize performance with attention to savings realization, inventory management, process design and documentation, KPI development, and reporting.
• Identify opportunities or gaps in current processes and implement solutions to improve team performance and customer experience.
• Cultivate relationships with key business partners in other functional areas and request/share feedback on interdependent process opportunities.
• Coordinate activities across departments (ex. FWA, Clinical, Legal, Customer Service, Claims) and external entities (ex. home plans or vendors).
• Develop capacity models and business cases to ensure support for growth.
• Deploy resources effectively across product lines with a balance between pre-service and pre-adjudication.
• Identify and maintain a list of system enhancements and analytic needs.
• Ensure timely resolution and notification of escalated cases.
• Track activity and produce reports to measure impact and document actions.
• · Support cross-functional projects and initiatives as a subject matter expert as needed.
• Support commercial teams in client meetings and finalist presentations as needed.
• Contact external 3rd parties through outbound call or email to obtain additional information or verify claim information.
• Validate accuracy of claim charges and initial processing decisions.
• Perform online research to fill in gaps in existing tools and understanding.

Requirements

• 5+ years of insurance industry or other relevant experience required.
• College degree or equivalent experience.
• Strong working knowledge of international health insurance claims.
• Knowledge of US Domestic health insurance claims is a plus.
• Prior experience identifying or investigating fraud, waste, and abuse is highly valued.
• Multi-lingual strongly preferred.
• Strong attention to detail and problem-solving skills.
• Excellent written and verbal communication skills.
• Demonstrated ability to build relationships and negotiate positive outcomes.
• Prior experience leading high performing teams in a fast-paced environment strongly preferred.
• Strong organizational skills, with the ability to manage multiple competing tasks at the same time.
• Ability to deal with ambiguity and drive for resolution.
• Willingness and ability to learn and apply new skills.
• Employee is required to have at minimum an internet speed of 75 Mbps (standard high-speed internet access).

Working conditions

• Flexibility to work in an office and/or at-home, remote office environment.
• Schedule flexibility is occasionally necessary in this position. Individual may be required to attend key business/departmental meetings and/or perform certain business critical job functions outside of normal working hours.
• Physical Demands: Must be able to communicate internally and externally through receiving and responding to auditory and visual methods.

This job description reflects management’s assignment of essential functions; it does not prescribe or restrict the tasks that may be assigned.