JOB PURPOSE:
Will be responsible for investigate claims / actions of potential healthcare fraud, waste & abuse activities (which includes onsite audit visits) and assist in educating & alerting the team members & stakeholders of possible FWA cases & trends by meeting or exceeding the set quality standard; delivering results in a timely and consistent manner, meeting all department quality and production goals and remaining current with all applicable business and audit processes.
JOB DESCRIPTION:
The specific duties in this role will include, but not limited to:
Key Responsibilities:
COMMUNICATIONS & WORKING RELATIONSHIPS:
Internal: Claims Manager, Medical Network & Relationship Manager, Enabling Function Manager, EB Sales Managers, and Medical Liaison Manager
External: Healthcare Providers, Policyholders, regulatory authorities.
QUALIFICATIONS, EXPERIENCE, & SKILLS:
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