Have you applied with us before?

Manager, Program Integrity

Manager, Program Integrity

Job Locations 
US-VA-Glen Allen
Job ID 
2018-4472

Job Description

Overview

The Program Integrity Manager is responsible for administering innovative fraud, waste, and abuse detection solutions for Medicaid & Medicare payers. This position will guide Medicaid and Medicare health care fraud detection efforts within the health plan. The individual will identify vulnerabilities within VPHP and payment vulnerabilities with providers. This position will develop policy & procedures and lead the data mining efforts to detect fraud, waste and abuse. The PI Manager will work closely with the Director of Program Integrity and the VP of Network Development to develop education and a recoupment methodology based on findings of audit activities that are designed to reduce or eliminate provider billing irregularities.

Responsibilities

  • Manage and implement the Program Integrity Plan for the health plan on an annual basis
  • Coordinate Program Integrity’s reporting needs for all lines of business
  • Execute provider audits to determine compliance with contract, and billing practices
  • Responsible for leading and completing the annual Program Integrity Compliance Audit
  • Develop policies & procedures and SOP’s for Program Integrity as needed
  • Identify, monitor and analyze aberrant patterns of utilization and/or fraudulent activities by healthcare providers through post payment review methodologies
  • Correlate review findings with appropriate actions (provider education, recovery of monies, cost avoidance)
  • Communicate with internal personnel, vendors, providers as deemed appropriate
  • Perform specific audit procedures and prepare work papers documenting & summarizing the audit procedure performed
  • Oversee the appeal process for all lines of business and all company appeals
  • Direct and monitor reports/findings generated by the Program Integrity Analyst
  • Other duties as assigned

Qualifications

MINIMUM EDUCATION REQUIREMENTS

  • Bachelors Degree in Health Care, Finance, Statistics, or a Science degree in the Healthcare field.

SPECIAL KNOWLEDGE AND/OR SKILLS

  • Must have inquisitive analytical and research skills.
  • Exposure to health care environment and knowledge of HCFA/CMS 1500 and UB04 claim forms
  • Strong verbal and written communication skills
  • Ability to work independently, meet deadlines, work under pressure and manage multiple priorities
  • Knowledge of HIPAA
  • Proven ability to analyze and present data

 WORK BACKGROUND/EXPERIENCE

  • Minimum of three (3-5) years experience in a Healthcare environment
  • Minimum of three (3) years audit experience
  • Six Sigma training preferred 

PHYSICAL REQUIREMENTS

  • Physical health sufficient to meet the ergonomic standards and demands of the position.

 

 

About Us

Virginia Premier is a managed care organization which began as a full-service Medicaid MCO in 1995. Partnered with VCU Medical Systems we strive to meet the needs of the underserved and vulnerable populations in Virginia by delivering quality driven, culturally sensitive and financially viable Medicare and Medicaid healthcare programs.  Headquartered in Richmond, VA we also have offices in Roanoke, Tidewater and Bristol with additional satellite locations allowing us to serve over 200,000 members across eighty counties throughout Virginia. 

 

We offer competitive salaries and a comprehensive benefits package to include excellent Medical, Dental and Vision Plans, Tuition Assistance, Infant-At-Work Program, Remote Work options and generous vacation and sick leave policies. Our culture supports an environment where employees can continuously learn and gain professional growth through various development programs, education, exciting projects and career mobility.  

 

All qualified applicants will receive consideration for employment without regard to age, race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status. EOE

 

Our mission is to inspire healthy living within the communities we serve!

 

Need help finding the right job?

We can recommend jobs specifically for you! Click here to get started.