Program Integrity Manager
Location: Seven Fields, PA
Build the Possibilities. Make an extraordinary impact.
Responsible for investigating, collecting, researching and analyzing billing data in order to detect fraudulent, abusive or wasteful activities/practices. Works with health plan leaders, oversees the monitoring and enforcement of the fraud, waste, and abuse compliance program to prevent and detect potential fraud, waste, and abuse activities pursuant to state and federal rules and regulations.
How you will make an impact:
Primary duties may include, but are not limited to:
- Assisting the team manager with the administration and operational activities occurring within the Special Investigations Unit
- Has detailed technical knowledge of claims payment accuracy and participates on cross functional teams focused on problem remediation and long term resolution.
- Anticipates the effect of changes in the business environment on future claim errors.
- Evaluates provider activities to assist in the detection of fraud, waste and abuse activities.
- Prepares final report and notification of findings letter suitable for distribution to providers and legal counsel.
- Monitors provisions of the compliance plan, including fraud, waste, and abuse policies and procedures, investigates unusual incidents and implements corective action plans.
- Develops and analyzes monthly reports.
- Develops project plans and oversees project execution, issue management and progress reporting.
- Develops processes to support early detection of systemic issues causing operational inefficiencies.
- Requires a BA/BS in Business, Engineering, Nursing, Finance, or Healthcare Administration and minimum of 5 years related work experience, including minimum of 2 years leadership experience; or any combination of education and experience, which would provide and equivalent background.
Preferred Skills, Capabilities and Experiences:
- MBA preferred.
- Investigative experience preferred
- Healthcare experience preferred
Please be advised that Elevance Health only accepts resumes from agencies that have a signed agreement with Elevance Health. Accordingly, Elevance Health is not obligated to pay referral fees to any agency that is not a party to an agreement with Elevance Health. Thus, any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.
Be part of an Extraordinary Team
Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. Previously known as Anthem, Inc., we have evolved into a company focused on whole health and updated our name to better reflect the direction the company is heading.
We are looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve. You will thrive in a complex and collaborative environment where you take action and ownership to solve problems and lead change. Do you want to be part of a larger purpose and an evolving, high-performance culture that empowers you to make an impact?
We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.
The health of our associates and communities is a top priority for Elevance Health. We require all new candidates to become vaccinated against COVID-19. If you are not vaccinated, your offer will be rescinded unless you provide – and Elevance Health approves – a valid religious or medical explanation as to why you are not able to get vaccinated that Elevance Health is able to reasonably accommodate. Elevance Health will also follow all relevant federal, state and local laws.
Elevance Health has been named as a Fortune Great Place To Work in 2021, is ranked as one of the 2021 World’s Most Admired Companies among health insurers by Fortune magazine, and a Top 20 Fortune 500 Companies on Diversity and Inclusion. To learn more about our company and apply, please visit us at careers.ElevanceHealth.com. Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact firstname.lastname@example.org for assistance.