VP Financial Invstgation &Provider Rev
Location: Pittsburgh, Pennsylvania
Description: Highmark Health Services is at present recruited VP Financial Invstgation &Provider Rev right now, this occupation will be situated in Pennsylvania. Further informations about this occupation opportunity kindly read the description below. GENERAL OVERVIEW:
Responsible for Highmark's program for monitoring provider billing activities to protect the Corporation's ! assets against fraud, waste and abuse in the payment for health care services. The focus of the program is Highmark's core health insurance market, with consultative services to the ancillary (dental, vision) lines of business, based on relative risk to the Corporation. This responsibility includes the development of a risk based fraud assessment program that identifies key risks, prioritizes these risks and develops appropriate action plans for cost avoidance, medical policy changes and/or recoveries from providers. The incumbent must also possess strong negotiation skills and the ability to interact with senior executives and attorneys on a regular basis.
Responsible for a team of approximately 65 employees, plus third party vendors, to monitor billing practices of providers and identify aberrancies in those practices; investigate potential billing errors, fraud, waste or abuse in the payment for health services; resolve identified issues, including education of ! the provider, negotiations with providers or their attorneys, ! escalation of issues to appropriate oversight bodies such as the Medical Review Committee, referral of cases to law enforcement for prosecution where appropriate, and/or referral to the Highmark Legal Department for civil action where appropriate; educate our many stakeholders about Highmark's program to monitor payments to providers; maintain or enhance networks and collaborative efforts with law enforcement and other insurers; and, maintain active roles in relevant professional and networking organizations. Work activities include both automated (technology) and manual processes. Additionally, data mining and extensive data analytics are an important function of this department and requires strong leadership by this position.
The incumbent has extensive interaction with the Chief Medical Director and staff, and the Medical Review Committee as necessary, a governance body existing pursuant to our enabling legislation which is charged with overseeing payment and me! dical necessity disputes between the Company and professional providers. The incumbent must possess strong communication and presentation skills at the Audit Committee and Board level.
ESSENTIAL RESPONSIBILITIES:
1.
Strong verbal and written communication skills. This position displays effective communication skills while performing the following functions:
Serve as the face of Highmark in the fight against health care fraud with our many stakeholders, including customers, regulators, members and providers.
Senior leadership and Board Interaction
Negotiations skills with Senior Leaders in Provider organizations
Audit Committee/Board level presentations
2.
Interact with Highmark operational, provider, reimbursement and medical policy senior management to continually refine FIPRs role in cost containment initiatives and medical policy changes.
3.
Develop strategy to successful! ly deliver obligations regarding fraud, waste and abuse for health serv! ices as well as for our Medicare C&D products.
Oversee development and implementation of tactical plans to accomplish the strategy.
Understand the requirements specified by the Centers for Medicare and Medicaid Services.
4.
Develop strategy and tactical plan to enhance Highmark's collaboration with law enforcement in the fight against health care fraud. Interact on a regular basis with law enforcement and assist on high profile cases as requested.
5.
Analyze total annual provider spend and ensure that FIPR strategies address all significant areas of spend. Develop a strategic plan to prioritize new initiatives to target changes high spend areas and implement strategies.
6.
Monitor the changing landscape in which the organization operates and ensure that strategy continues to be appropriate in the context of environmental, regulatory and legal changes. Continually educate and research new provider scheme! s to proactively fraud, waste, and abuse.
7.
Other duties as assigned or requested.
III. QUALIFICATIONS:
Minimum
Preferred
Bachelors Degree
10 years experience in health care industry, data analytics, auditing or criminal justice
15 years managerial experience
Knowledge, Skills and Abilities
Comprehensive knowledge of Highmark and its subsidiaries and affiliates
Comprehensive knowledge of Providers
Strong leadership skills
Excellent written and oral communication skills as well as presentation skills
Possess strong analytical skills
Strong negotiation skills and techniques
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If you were eligible to this occupation, please send us your resume, with salary requirements and a resume to Highmark Health Services.
Interested on this occupation, just click on the Apply button, you will be redirected to the official website
This occupation starts available on: Tue, 17 Sep 2013 00:50:21 GMT
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