Medicaid Fraud, Waste and Abuse Compliance Manager

Organization: Commonwealth Medicine Center for Health Care Financing (UMass Medical School)
Location: Schrafft's Building - Charlestown, MA
Job Number: 2014-24091
Category: Management


Job Description:

Located in Charlestown, MA, the Commonwealth Medicine Center for Health Care Financing (CHCF) helps state agencies, our primary clients, identify opportunities to increase savings and reimbursements through federal and other third party sources, establish effective savings and reimbursement programs and capitalize on all possible revenue streams. At the same time, we identify opportunities for our clients to increase health care related services and reduce the net cost of delivery.

The Provider Compliance Unit (PCU) ensures program integrity by identifying potential healthcare fraud, waste and abuse under federal and state regulations. Core activities of this unit include compliance with the Surveillance Utilization Review Subsystem (SURS), development and running of algorithms and conducting desk and onsite reviews (audits).

The PCU seeks a Manager/Lead Investigator to oversee staff who conduct desk reviews of Medicaid providers, such as Durable Medical Equipment and Transportation. This individual will also work on complex cases as assigned.

UMass Medical School is committed to being an equal opportunity and affirmative action employer and recognizes the power of a diverse community. We encourage applications from protected veterans, individuals with disabilities and those with varied experiences, perspectives and backgrounds to consider UMass Medical School as their employer of choice.

Review of applications will begin immediately and the position will remain open until filled.

Job Requirements
  • Provide supervision and guidance to staff
  • Direct all activities related to contract administration
  • Develop procedures to ensure quality, compliance, and accuracy in contract activities
  • Develop procedures to ensure compliance with state and federal regulations
  • Provide documentation and analysis to senior management to support identification of revenue opportunities
  • Manage the development of new contracts
  • Develop policies and procedures for workflow operations
  • Develop and monitor all contract reporting
  • Develop auditing and quality assurance procedures
  • Lead and participate in CQI activities within the program
  • Conduct performance evaluations and staff meetings
  • Perform other duties as required
  • Master’s degree in Business Administration, or equivalent experience
  • 1 to 3 years work experience in a management role
  • Business and financial experience preferred
  • Demonstrated experience using computer-based tools including electronic mail, word processing and database products
  • Prefer individual possessing any of the following certifications or licensure: CFE, CPA, RN/LPN, CPC, or CPMA
  • Advanced Microsoft Excel software skills
  • Knowledge of State and Federal regulations as they apply to public assistance programs
  • Experience in conducting data mining in the healthcare insurance industry and claims relate experience
  • Strong Decision making skills with the ability to investigate and weigh alternatives and select the appropriate course of action
  • Knowledge of the laws and regulations related to fraud and fraud investigations
  • Knowledge of coding, reimbursement and claims processing policies
  • Knowledge of the principles and practices of medical auditing
  • Excellent time management and organizational skills
  • Ability to develop and effectively implement complex auditing and QA procedures
  • Strong analytical and qualitative skills as well as problem solving skills with the ability to look for root causes and implement workable solutions
  • Must have a track record of producing high quality work that demonstrates attention to detail
  • Ability to multi-task, establish priorities and work independently to achieve objectives
  • Ability to function effectively under pressure
  • Excellent customer service skills with the ability to interact professionally and effectively with providers, third party payers, and staff from all departments
  • Strong interpersonal skills with the ability to work in a fast paced environment whether as a team member or an independent contributor
  • Strong oral and written communication skills including internal and external presentations
Additional Information:

Why join Commonwealth Medicine’s Provider Compliance Unit? If you join PCU you will be joining an elite group of professionals who strive to identify outliers and/or anomalies in data through statistical analysis and data mining. Come join a team who are subject matter experts in the domain identifying fraud, waste and abuse.

CWM offers a rewarding environment where cutting edge and pioneering health care and clinical services programs and projects are developed and managed.

If you are a high-energy, driven individual who loves a challenge and thrives in a fast-paced entrepreneurial environment, you are encouraged to submit your credentials for further consideration.

This position is in the Schrafft's Building, located in Charlestown, Massachusetts, just north of Boston and easily accessible by public transportation.


Apply Here: