Associate Director Program Integrity

Profile

Description

Are you looking to join a team where you can be a part of our important mission of supporting the TRICARE healthcare program for our nation's military? Humana Government Business is a top 10 Department of Defense contractor, with a long history in the TRICARE business and has recently been awarded the T-5 East Region, the next generation of military health contracts. The Associate Director of Payment Integrity is the leader of the team responsible for identifying fraud and abuse in TRICARE billings in the East Region and creating thorough evidence packages to present to the Defense Health Agency to substantiate fraud cases.

Responsibilities

This in office position will be based out of the Humana Clocktower Building, at 123 Main Street, Louisville, KY.

The Associate Director, Program Integrity will create and implement process improvement plans focused on the beneficiary and provider experience, as well as optimizing operational processes. The Associate Director will lead design and implementation of the process and experience for policy changes. Develop and monitor performance and quality of initiatives, providing insight and recommendations to the Program Integrity (PI) leaders. The Associate Director will oversee major process changes, be responsible for overarching project planning and deliverables for the PI team, work with vendors, as needed. Responsible for the management of the Fraud and Abuse staff in discovery, development, and coordination of fraud and abuse cases that are to be referred to Defense Health Agency (DHA) within contractual standards. Oversight function for DHA Lead Requests, hotlines and correspondence, as well as quarterly and annual reports. Responsible for oversight of balance billing, violation of participation agreements, as well as provider, beneficiary and associate fraud and abuse education. Oversight to the WPS Duplicate Claims System load completion to meet standards.

Required Qualifications

Our Department of Defense Contract requires U.S. citizenship for this position

Successfully receive interim approval for government security clearance (eQIP - Electronic Questionnaire for Investigation Processing)

8 years of experience in a healthcare or managed care setting

3 years of people leadership experience

3 years of experience in healthcare fraud investigations

Expertise and working experience in Project Management and/or Program Management to include problem solving and issues mitigation

Full and effective confidence of process improvement tools and methodologies and metrics commonly used

Demonstrated success in the planning and implementation of across-the-board process improvement initiatives to include both tactical and strategic-level projects

Ability to think analytically, apply analytical techniques and provide in-depth analysis of technical process, business process or raw data and make recommendations to management using critical thinking and sound judgement

Ability to interpret federal regulations and operations manuals

High level of proficiency with the Microsoft Office suite (Word, Excel, Outlook)

Preferred Qualifications

Bachelor's degree in business, healthcare administration, criminal justice or related field

Knowledge of or working experience with SQL and/or Tableau

AHFI (Accredited Healthcare Fraud Investigation) Certification

CFE (Certified Fraud Examiner)

AHIP Certification

CPC Certification

Experience in TRICARE or other federally regulated healthcare programs

Additional Information -

This position will lead a team of approximately 14 team members.

Scheduled Weekly Hours

40

Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our https://www.humana.com/legal/accessibility-resources?source=Humana_Website.

Company info

Humana Inc.
Website : http://www.humana.com