Medical Provider Performance Executive

Job description

This position is responsible for conducting objective, fair, thorough, unbiased, and timely investigations of healthcare providers for fraud, waste, and abuse committed against Allianz Group or its payers by members, providers, or other entities while monitoring best relationships with all parties.

The position requires ingenuity and creativity to obtain case information not readily available, along with the ability to work independently with minimum supervision. Good organizational skills are needed to manage a high volume of assigned cases as well as the regular exercise of independent judgment and initiative to investigate allegations.

The investigator must have the analytical ability necessary to review, interpret, and evaluate relevant information essential in resolving sensitive and complex investigations.

Responsibilities

• Fraud, abuse, and waste detection and prevention from medical providers for allocated regions and countries.
• Data mining and data analysis are required for conducting investigations on provider claims.
• Support and drive the savings target strategy as set by the global head of MPM.
• Review files, gather information, and collect evidence to detect fraud and abuse on claims.
• Document all evidence obtained in the investigation to substantiate meritorious claims, deny unjustified claims, recover inappropriate payments, or recommend action against responsible parties.
• Participate in onsite audits, in-house claims audits, and mystery shopping campaigns.
• Support the Medical Provider Performance Manager with all administration and support tasks to drive fraud detection and prevention.
• Assess the scope and determine the methodology needed to carry out an efficient investigation.
• Prepare comprehensive investigative reports and analysis.
• Collaborate and communicate internally with associated departments, i.e., legal, finance, claims operations, as well as external clients and providers.
• Consult with legal and regulatory authorities for cases that may involve legal action.
• Manage and ensure generation of periodic dashboards.
• Participate in specialized projects and assignments related to procurement, as required.
• Maintain provider relationships in coordination with the MPM team.
• Use judgment, diplomacy, and confidentiality with respect to the complete procurement process, ensuring integrity.
• Preserve the reputation of the company, beneficiaries, payers, and all other parties involved.

Requirements

• Medical background (MBBS doctor, nurse, paramedic).
• Coding certification such as CPC (Certified Professional Coder), CPMA (Certified Professional Medical Auditor), COC (Certified Outpatient Coder), CCS (Certified Coding Specialist).
• Work experience in the insurance industry with claim cycle management.
• Expertise in Excel, Power BI, and data analytics.
• Expertise in general industry trends.
• A thorough knowledge of the various types of insurance fraud and the strategies and techniques used in their investigation, as well as federal and state regulations.
• Strong interpersonal and relationship skills.
• Excellent written and verbal communication skills used for interviewing and corresponding with claimants, attorneys, doctors, law enforcement, etc.
• A high degree of integrity, dependability, accountability, and confidentiality is required for handling information that is considered personal and confidential.
• Ability to analyze data and interpret results.
• Ability to adapt and meet the changing demands of the work environment, including any delays or other unexpected demands.
• Ability to treat people with respect under all circumstances, instill trust in others, and uphold the values of the organization.
• Ability to collaborate and work with internal and external colleagues to successfully complete defined tasks and provide superior customer service.