Fraud, Waste, and Abuse Investigations Manager

* Responsible for fraud and abuse detection activities for the Tenn Care PBA Programs, including the Fraud and Abuse Compliance Plan. Will be responsible for day-to-day Provider investigation-related inquiries.
* Utilizes prescription and medical claim data to generate clinical recommendations according to "Global" Drug Utilization Review program protocols. Provides clinical recommendations pertaining to, but not limited to, gaps in care, high risk medications, compliance and adherence, drug interactions, therapeutic substitution, and generic substitution. Utilizes client formulary information to guide appropriate medication recommendations. Keep current with new and emerging clinical trends.

Provides active participation in departmental meetings to improve clinical programs and enhance processes. Share clinical information and department procedure protocols during client site visits. Assists the FWA Team with new clinical programs and system enhancements. Follow all policies and procedures related to job clinical support as needed for special projects and other duties as assigned by the Director, Compliance, FWA.

Perform other duties as assigned to meet departmental objectives.
* Under the guidance of the FWA Management, this position is responsible for the accurate and thorough clinical investigation of potential external fraud and abuse involving commercial and government lines of business. The scope of accountability includes investigating and remediating allegations of fraud, waste and abuse involving providers. Primary activities include substantiating referrals, case research and planning, conducting onsite or desk audits, clinical reviews of medical records to ensure correct billing of services and appropriateness of care, interviewing potential witnesses, developing corrective action plans, developing correspondence to impacted parties, managing disputes and collaborating with law enforcement and regulatory agencies.

Additional accountability includes cooperation of fraud, waste and abuse efforts with external business partners.
* Reviews medical and pharmacy records, researches and investigates complex cases for the purpose of detecting fraud both internal and external involving submission/payment of claims and identifies FWA issues for follow-up. The FWA Investigation Manager interprets a variety of documents including, but not limited to client contracts, group benefit structures, Workplan Policies and Procedures, governmental policies as well as diverse regulatory and legal requirements.
* In conjunction with the FWA Clinical Pharmacist, thoroughly researches an allegation or issue and develops sources of information to create a plan of action, accumulating sufficient detailed evidence including statements, documents, records, exhibits, and photographs for the successful adjudication of identified FWA cases or audit results.
* Makes sound rational clinical judgments and decisions in the progression of their cases, keeping management routinely apprised of the progress.
* Requests and analyzes data in order to identify fraudulent billing patterns.
* Solves problems using sound professional judgment to determine the appropriate course of action and independently follows through, when necessary.
* Provides routine interaction, referrals, and coordination with Medicaid, CMS, NICB, MEDIC, local, state and federal law enforcement, and regulatory licensing boards.
* Monitors the regulatory interactions with our network of providers, prescribers, and members.
* Functions independently with appropriate oversight in sensitive situations.
* Evaluates situations accurately and interacts frequently with managers, supervisors, and legal to ensure complex issues are addressed appropriately.
* Prepares comprehensive Reports of Findings and prepares cases for potential prosecution and civil settlement by documenting findings in a clear and concise manner.
* May be required to review files and testify in court or the Credentialing Adjudication Committee, as needed, in matters regarding litigation/adjudication related to their reviews.
* Manages cases as assigned, prioritizing case load as appropriate. Maintains case logs, prepares records and regular status reports.
* Interacts frequently with providers of health care, often under adverse conditions due to potential discovery of fraud, waste or abuse. The incumbent shall discuss sensitive material in a professional, fair and accurate manner.
* Acts as primary point of contact with law enforcement for assigned cases in conjunction with the FWA Investigator.
* Interprets various data analyses and information gathered in the detection process, determines what information to analyze further and what trends or issues to report to others.
* Prepares recommendations on preventive/corrective measures for the deterrent of future fraud.
* Supports other FWA personnel and analysts with their cases by providing medical information/expertise and as necessary, performs clinical reviews of…