Manage and have overall performance accountability for the Healthcare Claims Audit & FAW (Fraud, Abuse & Waste) department. Provide Audit, investigation and claims quality solutions. Responsible for setting-up and Operationalizing the Claims Audit & FAW processes and tools.
•Bachelor’s Degree in Forensic Science, Criminal Justice, Healthcare, or a related field or equivalent experience preferred.
•Leadership skills, assertive with self-confidence and strong personality
•10+ years of Experience in professional liability, legal implications, fraud, insurance contracts, Health Claims Management, medical processes and IT tools
•Substantial knowledge of health care fraud and abuse laws and regulations
•Demonstrated understanding of common fraud schemes and ability to review and evaluate assigned referrals and apply appropriate investigative strategies as needed.
•Strong knowledge of standard industry coding guidelines such as CPT, HCPCS, ICD 10 and NCCI.
•Ability to independently develop and present verbal and written investigative and management reports.
•Demonstrated business acumen, including the ability to see the 'big picture' as well as the relationship of very detailed and specific business issues