|Location: Lee's Summit, MO
Manages the compliance plan with OPM contract requirements to identify, investigate, report, and manage medical fraud, waste and abuse (“FWA). Responsible for development of the unit budget, as well as internal and external operations of the Special Investigations Unit (“SIU”). Implements and maintains a fraud, waste, and abuse identification tool and ensures use of the tool. Investigates FWA cases as appropriate. Maintains a robust documentation and reporting system to track and report fraud, waste, and abuse cases, consistent with OPM contract and OIG requirements. Ensures department work is integrated with other involved department(s), provider network vendor(s), and prescription benefit manager(s), provider records management, call center, cost recovery department and claims operations to promote efficiencies and prevent delays in fraud, waste, and abuse actions. Responsible for FWA training for GEHA workforce on an annual basis and for providing on-going training to new GEHA employees as needed. Responsible for assuring that staff receives FWA training and assists staff with obtaining and maintaining the AHFI designation. Collaborates with the GEHA compliance committee and internal audit department to identify cases and demonstrate compliance with the GEHA/OPM contract and carrier letter requirements. Manages mobilization and engagement of staff to accomplish department and corporate goals.
• Manages the internal and external work of the unit. Determines the work processes and develops the associated workflows, policies and audit tools needed to guide the work of the team. Creates audit tools that ensures the unit’s compliance with the work processes. Ensures the unit work is done efficiently and doesn’t create unnecessary delays in claims payment(s) and collections.
• Develops documentation guidelines and ensures record systems are configured to account for all cases and maintain accurate records of suspected FWA activity throughout the life of each case. Ensures proper documentation and provider flags are placed in GEHA systems.
• Develops and monitors program goals consistent with the corporate strategic plan and OPM/OIG directives. Regularly evaluates Plan exposure to FWA risks, the FWA program effectiveness and staff performance. Identifies program gaps and opportunities, recommends action, and deploys staff to implement improvements and resolve issues affecting the FWA program.
• Provides oversight of the investigative capabilities of the unit, ensuring appropriate notifications to OIG and appropriate referrals to local, state, and federal agencies.
• Facilitates integration with other teams; including, but not limited to the clinical editor team, the Macess or other work distribution team, Facets team, Care Management team, Pharmacy team, Claims team, Appeals team, and Overpayment Recovery team. Provides education to the organization to enlist the help of the GEHA employees in the identification of fraud, waste, and abuse.
• Interfaces with and cooperates with the GEHA Compliance Committee and Internal Audit team to identify and report FWA and demonstrate compliance with OPM contract. Represents the SIU during OPM OIG audits and is responsible for creating follow up reporting and issue resolution.
• Participates in the GEHA plan accreditation process with respect to risk management.
• Creates, maintains, and reviews internal and external reporting to account for cases under management and the associated savings. Creates reports for senior leadership as requested. Completes required reporting of OPM OIG and other as required in the OPM contract, Carrier Letters, and OIG audits.
• Oversees the external tools used for fraudulent case identification and ensures contract compliance. Ensures team is educated regarding use of the tools and coordinates regular training updates as needed.
• Develops processes for case development, investigation, and case presentation to OPM OIG, federal and state agencies and/or local law enforcement. Establish and maintains contacts with agencies as appropriate.
• Develops and updates as necessary FWA manuals required by OPM contract and industry standards.
• Manages mobilization and engagement of staff needed to accomplish department and corporate goals. Conducts regular meetings to communicate department and organizational information. Ensures staff is adequately trained and encourages staff certification for personal development and enhanced case review.
• Prepares department budget for Vice President’s approval. Monitors and manages the budget. Reports monthly and quarterly budget variance and explains the rationale for all variances. Ensures Vice President is apprised of budget concerns in a timely manner. Assists unit to understand the annual budget constraints.
• Takes an active role in NHCAA Membership Forum and other appropriate organizations (such as NICB) to receive current information on health care fraud, management issues and government affairs. Build relationships with carriers and law enforcement through NHCAA membership.
• Participates in OPM OIG quarterly carrier meetings devoted to FWA issues to keep updated with current major investigations, reporting requirements and case sharing. Develops relationships with other FEHB SIU management.
• Ensures appropriate legal research on suspect providers, evaluating state regulations and state licensing requirements. Reports appropriate cases to state boards and law enforcement, if appropriate.
• The incumbent is required to obtain knowledge of GEHA’s Affirmative Action policy and make decisions regarding employment, promotion, and termination of employees that comply with its principles.
Requires a Bachelor's Degree.
• Requires 5 years leadership experience in a Special Investigations Unit in a health plan setting.
• Requires 5 years of experience in insurance with knowledge of claims processing, provider credentialing processes, and understanding of clinical services billed to a health insurance company. Health insurance experience is preferred.
• Requires 2 years of experience working with federal and state agencies and law enforcement.
• Requires experience using Fraud, Waste and Abuse (FWA) documentation systems, ability to use a personal computer and MS Word and MS Excel.
• Requires FWA certification: AHFI or CFE.
GEHA will not discriminate against employees or applicants because they have inquired about, discussed, or disclosed their compensation or the compensation of another employee or applicant. GEHA is an Equal Opportunity Employer with five locations in the Kansas City metropolitan area. Our company's corporate headquarters is located in Lee's Summit near Douglas Rd and I-470. The claims processing office and call center is located in Independence near Little Blue Parkway and I-70. All offices are easily accessible by freeway from anywhere in the Kansas City metro area.