Manager - Claims Integrity

Job Overview

We are seeking a Manager - Claims Integrity to conduct comprehensive reviews and analyses of Fraud, Waste, and Abuse (FWA) related cases, alerts, and claims patterns. This role involves evaluating medical claims, documenting evidence, supporting decision making, and driving recovery efforts while contributing to the enhancement of claims integrity controls and processes.

Key Responsibilities

• Thoroughly examine FWA cases, alerts, suspicious provider and member behaviors, and claims patterns to identify potential issues.
• Evaluate claim details, including medical justifications and billing patterns, to uncover possible fraudulent activities.
• Document findings extensively to underpin decisions, recoveries, escalations, or additional reviews.
• Organize collected data and evidence to facilitate negotiation processes regarding fraudulent claims.
• Collaborate with the provider relations team to substantiate evidence and negotiate recoveries aligning with target forecasts.
• Prepare necessary reports and escalate cases to regulators when required.
• Monitor and analyze recurring claims behaviors, market practices, provider trends, and emerging FWA patterns.
• Spot new or evolving misuse activities necessitating new controls, rules, or process modifications.
• Offer constructive feedback to improve claims integrity controls and detection methodologies.
• Support recovery efforts by delivering validated findings and rationale, coordinating with stakeholders for proper implementation.
• Highlight operational gaps, false positives, and challenges, proposing process enhancements.

Required Skills and Qualifications

• Minimum of 2 years of medical practice and insurance experience.
• Strong analytical and investigative abilities to detect suspicious patterns, emerging trends, and control deficiencies.
• Proficient documentation skills to prepare case summaries, evidence packages, and support materials for decisions.
• Problem-solving aptitude to provide actionable feedback for process and control improvements.
• Effective communication and coordination skills to engage with teams across claims integrity, medical, provider management, recovery, and operations.
• Bachelor’s degree in Medicine (M.B, B.S./M.D, or equivalent).
• Solid understanding of claims integrity, FWA, medical audit, claims processing, and healthcare insurance controls.
• Detailed-oriented with dedication to accuracy, consistency, evidence quality, and audit trail maintenance.
• Familiarity with claims management systems, case workflow tools, dashboards, Excel, and reporting software is advantageous.
• Digital literacy to utilize cases systems and analytical platforms effectively for case review, pattern analysis, and process improvement support.