Humana Hiring for Manager of Fraud and Abuse Data Analytics at Jersey City, New Jersey Full Time

Description

Responsibilities

The Manager of Fraud and Abuse Data Analytics will be responsible for the supervision 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). This position is also the oversight function for DHA directives and correspondence.

KEY ACCOUNTABILITIES

• 30% Manages Program Integrity team with responsibility for the quality and content of proactive case referrals to the Program Integrity Sr. Fraud and Waste Investigators. As part of this function, establishes familiarity with the various TRICARE Policy Manuals and ensures compliance with applicable Program Integrity sections of awarded contract. Referrals must be of a quality that will ensure annual standard of 20 overall case referrals to the Defense Health Agency Program Integrity is met.

• 20% Creates team engagement and develops associates through coaching, guiding and providing timely feedback, as well as yearly performance appraisals

• 20% Creates and maintains functionality of all Program Integrity databases, Tableau dashboards, and reports.

• 20% Management of Fraud and Abuse Researchers and Technicians to ensure all fraud case development support occurs timely

• 10% Interacts with other departments throughout Humana Military to create a corporate commitment and cultural awareness of fraud and abuse. This function will oversee education and publications directed towards providers, beneficiaries and associates. It will also coordinate related efforts with Claims Oversight, Provider Network Operations, Claims Cost Management, IT, and Medical Management

This role description in no way states or implies that the key accountabilities above are the only ones being performed by the individual(s) with this role description. The individual(s) may be called upon and required to follow other instructions or perform other duties and tasks requested by his or her supervisor, consistent with the purpose of the position, department and/or company objectives .

Required Qualifications

• 5 plus years of healthcare claims experience

• Prior fraud and abuse experience

• Three years supervisory/leadership experience

• Strong communication, analytical ability and research skills

• Ability to interpret federal regulations and operations manuals

• Microsoft Office (Word, Excel, Outlook) Proficient to include MS Access

• Proficiency with SQL and/or Tableau

• 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)

• We will require * full COVID vaccination* for this job as we are a healthcare company committed to putting health and safety first for our members, patients, associates and the communities we serve.

• If progressed to offer, you will be required to provide proof of full vaccination or documentation for a medical or religious exemption consideration. Requests for these exemptions should be submitted at least 2 week prior to your scheduled first day of work.

Work at Home/Remote Requirements

• Must ensure designated work area is free from distractions during work hours and virtual meetings

• Must provide a high-speed DSL or cable modem for a workspace (Satellite and Hotspots are prohibited). A minimum standard speed of 10×1 (10mbs download x 1mbs upload) for optimal performance of is required

Preferred Qualifications

• Bachelor’s degree or Master’s degree

• Experience in a system analytics and/or data warehousing environment

• Experience in TRICARE or other federally regulated healthcare programs

Additional Information

As part of our hiring process, we will be using an exciting interviewing technology provided by Modern Hire, a third-party vendor. This technology provides our team of recruiters and hiring managers an enhanced method for decision-making.

If you are selected to move forward from your application prescreen, you will receive correspondence inviting you to participate in a pre-recorded Voice Interview and/or an SMS Text Messaging interview. If participating in a pre-recorded interview, you will respond to a set of interview questions via your phone. You should anticipate this interview to take approximately 10-15 minutes.

If participating in a SMS Text interview, you will be asked a series of questions to which you will be using your cell phone or computer to answer the questions provided. Expect this type of interview to last anywhere from 5-10 minutes. Your recorded interview(s) via text and/or pre-recorded voice will be reviewed and you will subsequently be informed if you will be moving forward to next round of interviews.

Scheduled Weekly Hours

40