Fraud, Waste, and Abuse Investigations Manager

About the role

The Fraud, Waste, and Abuse Investigations Manager handles the operational activities related to Pharmacy Compliance, FWA. This will require close partnership and collaboration with a cross-functional group of leaders. It will be essential to have outstanding program management skills, as well as exceptional interpersonal, communication and relationship building skills. This position reports to the Director, Strategic Account Management and their primary role is performing consultations with related parties to complete comprehensive investigations and improve surveillance of FWA. The FWA Investigations Manager will document the intervention and communicate essential information to the client team for dissemination to clients. This position will be the point of contact for client SIU's and Pharmacy Audit teams. Primary Responsibilities Responsible for fraud and abuse detection activities for the state defined PBA Programs, including the Fraud and Abuse Compliance Plan. Will be responsible for day-to-day Provider investigation-related inquiries. Utilizes prescription and medical claim data to generate clinical recommendations according to "Global" Drug Utilization Review program protocols. Provides clinical recommendations pertaining to, but not limited to, gaps in care, high risk medications, compliance and adherence, drug interactions, therapeutic substitution, and generic substitution. Utilizes client formulary information to guide appropriate medication recommendations. Keep current with new and emerging clinical trends. Provides active participation in departmental meetings to improve clinical programs and enhance processes. Share clinical information and department procedure protocols during client site visits. Assists the FWA Team with new clinical programs and system enhancements. Follow all policies and procedures related to job clinical support as needed for special projects and other duties as assigned by the Director, Compliance, FWA. Perform other duties as assigned to meet departmental objectives. Under the guidance of the FWA Management, this position is responsible for the accurate and thorough clinical investigation of potential external fraud and abuse involving commercial and government lines of business. The scope of accountability includes investigating and remediating allegations of fraud, waste and abuse involving providers. Primary activities include substantiating referrals, case research and planning, conducting onsite or desk audits, clinical reviews of medical records to ensure correct billing of services and appropriateness of care, interviewing potential witnesses, developing corrective action plans, developing correspondence to impacted parties, managing disputes and collaborating with law enforcement and regulatory agencies. Additional accountability includes cooperation of fraud, waste and abuse efforts with external business partners. Essential Duties and Responsibilities include the following. Other duties may be assigned. Reviews medical and pharmacy records, researches and investigates complex cases for the purpose of detecting fraud both internal and external involving submission/payment of claims and identifies FWA issues for follow-up. The FWA Investigation Manager interprets a variety of documents including, but not limited to client contracts, group benefit structures, Workplan Policies and Procedures, governmental policies as well as diverse regulatory and legal requirements. In conjunction with the FWA Clinical Pharmacist, thoroughly researches an allegation or issue and d

Benefits

Additional Information

Exemption Status: United States of America (Exempt) $85,356 - $115,232 - $145,107 "Pay scale information is not necessarily reflective of actual compensation that may be earned, nor a promise of any specific pay for any selected candidate or employee, which is always dependent on actual experience, education, qualifications, and other factors. A full review of our comprehensive pay and benefits will be discussed at the offer stage with the selected candidate." This position is not eligible for Sponsorship. MedImpact Healthcare Systems, Inc. is looking for extraordinary people to join our team! Why join MedImpact? Because our success is dependent on you; innovative professionals with top notch skills who thrive on opportunity, high performance, and teamwork. We look for individuals who want to work on a team that cares about making a difference in the value of healthcare. At MedImpact, we deliver leading edge pharmaceutical and technology related solutions that dramatically improve the value of health care. We provide superior outcomes to those we serve through innovative products, systems, and services that provide transparency and promote choice in decision making. Our vision is to set the standard in providing solutions that optimize satisfaction, service, cost, and quality in the healthcare industry. We are the premier Pharmacy Benefits Management solution! Job Description

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