The Manager, Investigations & Claim Audit is responsible for managing the fraud, waste & abuse program in compliance with the Uniform Managed Care Contract and the Office of Inspector General rules and regulations.This includes working with the contracted Special Investigations Unit, conducting preliminary investigations, provider education, recoupment and reporting relating to potential fraud, waste and abuse.This position is also responsible Claims Auditing by ensuring a minimum 5% of adjudicated claims are audited on a monthly basis and communicating the results to the Claims Department, providing production reports and for reviewing the Medicaid Banners and Bulletins and sending a summary of the changes to the management, claims and configuration teams.
Bachelor's Degree or equivalent insurance or managed health care experience required.
Six years of claims/audit experience, including a minimum of three years in a claims processing environment.
Extensive knowledge of claims processing.
Advanced knowledge of medical benefits, medical terminology and coding.
Advanced knowledge of claim adjudication and benefit plan application for HMO plans and Medicaid.
Advanced Microsoft Office skills including Word, Excel and Access.
Excellent customer service skills with ability to explain complicated benefit issues to providers and diffuse hostile encounters.