Health Alliance Plan
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 Lead Auditor to join our team. 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.
Develop, implement and manage strategic fraud, waste, and abuse activities by maintaining state and federal requirements and monitoring trends and schemes. Responsible for planning, organizing, directing, implementing and leading department assignments. Deliver guidance and mentoring to team members. This position will provide senior level expertise in fraud, waste, and abuse analytics, and strategic decision making as it relates to compliance requirements and medical cost savings initiatives. Lead the team appropriately on investigations of all possible fraud, waste, and abuse referrals. Develop educational materials to address/identify waste activities as requested by the health plan and on an ad-hoc basis. Attend state and federal meetings as required by specific contracts. Prepare and distribute monthly, quarterly, and annual savings reports. Prepare and deliver presentations in a clear and concise manner to communicate findings from audits to management, provider groups, and other stakeholders. Consult with business unit leaders and employees regarding implementation of initiatives and support decision making.
PRINCIPAL DUTIES AND RESPONSIBILITIES:
- Formulate plans to develop an ongoing process to identify opportunities for recovering erroneous or fraudulent claims.
- Possess and maintain in-depth knowledge of HAP business, products, programs (including claims reimbursement, benefits, provider and program data, networks etc.) and complex research principles/ methodologies.
- Identify, evaluate and implement other opportunities for cost savings (not necessarily related to claims payments) or revenue enhancements through operational audits or other means.
- Provide mentoring and guidance to team members. Ensures integrity and reporting accuracy of the department.
- Serve as a subject matter expert and consultant to HAP’s senior leadership. Develop solutions to complex issues and present recommendations to senior management as well as employees at various corporate levels.
- Develop, implement and maintain data mining activities and data analysis using available tools.
- Is the point of contact for all fraud, waste, and abuse vendors.
- Participate in meetings with Providers to explain audits and required corrective action.
- Act as liaison with other departments regarding Provider-related inquiries such as overpayments, settlements, and other financial issues arising from Payment Integrity activities.
- Act as a health care consultant by developing strategies and programs to reduce health care benefit costs and improve quality of care. Collaborate with appropriate business areas to implement proposed solutions and manage programs to evaluate effectiveness and results.
- Perform other duties as assigned.
- Must have a coding credential from AHIMA or AAPC (i.e., CCS, CCS-P, RHIA, RHIT, CPC, etc.)
- Minimum of five (5) years progressive experience in healthcare or managed care/insurance related setting with specific exposure to provider contracting and reimbursement data and methodologies as well as case management, disease management, patient/member data, and fraud, waste, and abuse.
- Minimum two (2) years of experience in leading projects as a project lead and/or lead subject matter expert.
- Demonstrated experience with technical coding concepts and a strong understanding of fraud, waste, and abuse.
- Demonstrated experience analyzing and reviewing fraud, waste, and abuse reports.
- Advanced coding knowledge with practical application.
- Excellent analytical, problem solving, verbal and written skills to communicate complex ideas.
- Excellent skills with ability to integrate and co relate information from different domains and subject areas.
- At least three (3) years of experience in leading staff in projects or supervisory/management position preferred.
- Strong team player with high level of integrity.
- Flexible, self-driving, resourceful, highly focused and high attention to detail.
Preferred Qualifications: Education Qualifications:
- Bachelor’s degree in Business Administration, Economics, Health Care, Finance, Information Systems, Statistics or other related field
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/HENRYFORDYpC62a
Apply Online: http://p.rfer.us/HENRYFORDYpC62a