Health Alliance Plan (HAP)
Health Alliance Plan (HAP)
Health Alliance Plan (HAP) is a nonprofit, regional health plan based in Detroit, Michigan and a subsidiary of the Henry Ford Health System. We are actively recruiting a Director – Payment Integrity to join our team in our Southfield, Michigan office. HAP provides health coverage to more than 670,000 members and to companies of all sizes. For more than 50 years, HAP has partnered with leading doctors and hospitals, employers and community organizations to improve the health and well-being of its members. HAP offers a product portfolio with six distinct product lines: Group Insured Commercial, Individual, Medicare, Medicaid, Self-Funded and Network Leasing. HAP delivers award-winning preventive services, disease management, wellness programs and personalized customer service. The National Committee for Quality Assurance has awarded HAP’s commercial HMO and HAP Senior Plus Excellent Accreditation.
Responsible for developing and implementing an analytically driven approach to fraud and abuse identification and prevention. Responsible for creating and implementing detection, recovery and prevention processes to reduce unnecessary medical expense. Develops and implements the long-term strategy for creation, quantification, and implementation of fraud and abuse services across the company. This position will be responsible for the day to day operations of the Payment Integrity team to include project assignments, review of reports, and staff developmental issues. Responsible for ensuring HAP remains in and can demonstrate compliance with all federal and state statutes and contract requirements relating to fraud, waste, and abuse. Oversees the direct accountability to ensure compliance with federal and state regulations; development, implementation and coordination of all fraud, waste, and abuse activities and program requirements including areas with no direct reporting.
Principal Duties and Responsibilities:
- Provides complete oversight of fraud and abuse initiatives, identifies new opportunities, and provides monthly reporting of successes and barriers. Project manages cross-functional corporate business teams and meetings in the development of fraud and abuse initiatives, baseline targets, and results as they relate to specific corporate strategies and programs.
- Oversight of all fraud, waste, and abuse requirements, including routine audits, reporting to third parties, investigations, education, outreach, publications, and effectiveness reviews.
- Strategic planning and vision of the fraud, waste, and abuse and payment integrity program to ensure HAP is in compliance with federal and state statutes and regulations.
- Makes decisions that have significant and broad impact to cross-sections of the company.
- Advises and assists with the development and implementation of processes to reduce risk to the organization.
- Identify and address potential areas of fraud, waste, and abuse or payment integrity risks.
- Serve as the point person and advocate for fraud, waste, and abuse and payment integrity matters.
- Refine and sustain a mechanism to ensure timely and consistent reporting of fraud, waste, and abuse activities as required by government agencies and federal contracts.
- Oversee and directly accountable for all investigations and audits are conducted as required by law and federal contracts and performed in a continuous and systematic manor.
- Understand and communicate to leadership and the Corporate Compliance Committee the breadth and complexities associated with fraud, waste, and abuse regulatory requirements.
- Maintain a matrix and direct oversight and central reporting of vendors impacting healthcare affordability and medical trend management.
- Assess preparedness for new and emerging fraud, waste, and abuse trends, schemes, and draft regulations.
- Direct and oversee all activities of the Payment Integrity team to ensure that all commitments are met, target budgets are achieved and resources are used effectively and efficiently. Organize, coordinate and ensure the team adheres to departmental standards, policies and procedures.
- Drives the development of best in class and forward thinking methods/criteria for identifying and correcting fraud and abuse issues. Integrates information from multiple sources, discerns implications for future analysis and identifies opportunities for enhancing integrity of medical data.
- Works in conjunction with external vendors to implement best in class programs that are needed within the organization.
- Coordinates with Compliance Department to satisfy governmental programs fraud, waste and abuse requirements (Medicare, FEHB and Medicaid).
- Partners with IT, Finance, Product Management and Market Intelligence, Claims, Client Services and areas within Health & Network Management to champion, develop, and monitor fraud and abuse initiatives for medical and/or network management programs.
- Prepares and delivers well-organized and compelling presentations to reflect key findings, analytic methods to determine such findings, future analysis and implications; and the identifications of opportunities to drive business improvements.
- Create reporting that identifies trends and patterns of fraud and abuse through data analysis.
- Performs cost benefit analysis for key organizational programs and initiatives impacting medical cost and performance.
- Assures compliance with sound principles of economic assessment and uses explanatory and predictive models in the development, support and analysis, and determining the value of future medical management initiatives.
- Performs other related duties as assigned
- Certified coding credential (RHIT, RHIA, CPC, CPC-P, CPCH, CCS, CCS-P) preferred
- Minimum of three (3) years in a management role directing fraud and abuse programs or related activities for a manage care, health insurance, pharmaceutical or other health related organization required.
- Minimum of three (3) years of experience in leading staff in projects or supervisory/management position required.
- Demonstrated experience with data interpretation, analysis, and reporting; clinical and financial data; predictive modeling and forecasting; key performance indicators as it relates to medical cost data.
- Demonstrated project management experience in running corporate wide projects
- Nature of the work requires progressive interpersonal communication, decision making, financial and technical skills; ability to introduce new ideas, processes, measures and tools to improve healthcare performance
- High energy; strong leadership, analytical, project planning and coordination skills to enable efficient, timely task completion of deliverables that meet or exceed customer expectations.
- Demonstrated ability to function in a creative, “out-of-the-box” thinking in order to develop original solutions to overcome roadblocks and meet or exceed customer requirements and expectations.
- Knowledge of medical claims data and managed care membership data
- Knowledge of business intelligence applications, data, and tools
- Advanced technical skills which includes, but is not limited to, MS Access and Excel skills
- Knowledge of Medicare and Medicaid Reimbursement methodologies a plus.
Preferred Qualifications: Education Qualifications:
- Bachelor’s Degree in Finance, Accounting, Statistics, Health-related Science or Computer Science. Masters degree preferred.
Henry Ford Health System offers family health, dental, and retirement plan options. More details will be provided during the interview process.
Instructions for Resume Submission:
To apply- please follow the attached link http://p.rfer.us/HENRYFORDuUu62f
Apply Online: http://p.rfer.us/HENRYFORDuUu62f