Payment Integrity and Fraud Lead

Job not on LinkedIn

🔥 47 minutes ago

🐊 Florida – Remote

🐊 Florida – Remote

💵 $83.3k - $145.8k / year

⏰ Full Time

🟠 Senior

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PacificSource Health Plans

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 1933

🏥 Healthcare

🛡️ Insurance

⚕️ Healthcare Insurance

Healthcare • Insurance • Healthcare Insurance

PacificSource Health Plans is a healthcare provider that offers a range of health insurance solutions, including plans for individuals, families, and employers. Their offerings include Medicare and Medicaid plans, dental coverage, and administrative services for small and large groups. Committed to member care, PacificSource emphasizes customer service and provides various resources for health management, including mental health support and wellness programs.

📋 Description

• Provide direct supervision, coaching, performance management, and professional development for assigned Payment Integrity and FWA staff • Supervise and direct payment integrity claims adjustment activities, ensuring timely and accurate implementation of claim corrections, recoveries, and financial adjustments • Oversee recovery inventory management and ensure identified overpayments, audit findings, and recovery opportunities are appropriately processed, tracked, and resolved • Coordinate daily work activities, workload prioritization, inventory management, and resource allocation across payment integrity functions • Support the execution and on-going operations of pre-payment and post-payment payment integrity programs, including audits, claims reviews, recoveries, and fraud prevention activities • Oversee the investigation, tracking, documentation, and resolution of potential fraud, waste, and abuse referrals and cases • Monitor payment integrity performance metrics and recovery results and prepare reports for leadership, compliance committees, and regulatory agencies as needed • Implement and maintain payment integrity policies, procedures, workflows, and operational controls • Ensure compliance with applicable federal and state regulations, CMS requirements, contractual obligations, and internal policies • Serve as a primary operational liaison between Payment Integrity, Compliance, Claims Operations, Provider Relations, Finance, and Special Investigations functions • Coordinate day-to-day operational activities with external vendors supporting audit, recovery, analytics, and fraud detection programs and monitor adherence to established service levels • Review audit findings, recovery opportunities, and investigative outcomes to ensure consistency, accuracy, and adherence to established standards • Support preparation and submission of regulatory reporting requirements related to fraud, waste, abuse, and payment integrity activities • Participate in internal and external audits and assist with corrective action planning and implementation • Identifying emerging risks, payment vulnerabilities, billing trends, and opportunities for program improvement and escalate recommendations to leadership • Lead or participate in departmental projects, process improvement initiatives, and cross-functional workgroups • Actively participate as a key member of management and leadership meetings • Represent Payment Integrity on internal committees and workgroups as assigned • Coordinate business activities by maintaining collaborative partnerships with key departments • Assist with hiring, staff development, coaching, performance reviews, corrective actions, and termination of employees • Actively participate as a key team member in department meetings • Actively participate in various strategic and internal committees in order to disseminate information within the organization and represent company philosophy.

🎯 Requirements

• Minimum of 4 years of senior-level healthcare operations, payment integrity, fraud prevention, claims auditing, claims administration, or related experience required • Prior supervisory experience preferred • Bachelor’s degree required • Candidates with an associate’s degree and 2 years of relevant experience, or a high school diploma and 4 years of relevant experience will also be considered • Knowledge of healthcare claims processing, reimbursement methodologies, coding systems, and payment integrity concepts • Knowledge of fraud, waste, and abuse regulations and investigative practices • Understanding of Medicare, Medicaid, and commercial health plan regulatory requirements • Knowledge of ICD-10, CPT, HCPCS, DRG, and related reimbursement methodologies • Strong analytical, problem-solving, and decision-making skills • Ability to interpret data, identify trends, and develop operational recommendations • Ability to communicate effectively with leadership, regulators, providers, vendors, and cross-functional business partners.

🏖️ Benefits

• Flexible telecommute policy • Medical, vision, and dental insurance • Incentive program • Paid time off and holidays • 401(k) plan • Volunteer opportunities • Tuition reimbursement and training • Life insurance • Options such as a flexible spending account