Manager Insurance Siu Jobs Near Me

Employment Type:Full timeShift: Description:

Why MediGold?

MediGold is a not-for-profit Medicare Advantage insurance plan serving seniors and other Medicare beneficiaries across the United States. We’re dedicated to providing excellent customer service, cost-effective care, and exceptional healthcare coverage. We rely on talented colleagues in a wide variety of professional roles including information technology, financial analysis, audit, provider relations and more.

We know that exceptional patient care starts with taking care of our colleagues, so we invest in great people and all that we ask in return is that you come to work ready to make a difference and do the right thing. 

What we offer:

• Competitive compensation and benefits packages including medical, dental, and vision coverage
• Retirement savings account with employer match starting on day one
• Generous paid time off programs
• Employee recognition incentive program
• Tuition/professional development reimbursement
• Relocation assistance (geographic restrictions apply)
• Discounted tuition and enrollment opportunities at the Mount Carmel College of Nursing

Why Columbus?

The nation's 14th largest city, Columbus, Ohio is one of the fastest growing major metropolitan areas in the Midwest – ranked #1 for population growth, #1 for job growth, #1 for wage growth, and #1 real estate market. And with a vibrant blend of professional sports, world-class attractions, creative cuisines, and a flourishing music and arts scene, you'll never be found wanting for entertainment and experiences to call your own in Columbus. Learn more at www.experiencecolumbus.com

About the job:

Program Manager - MCHP is responsible for managing a program spanning multiple years and typically confined to a single business unit and/or function. Provides day-to-day leadership and guidance of the SIU. Coordinates and is accountable for Support Services activities related to anti-fraud management for Mount Carmel Health Plan.

What you'll do:

• Participates in appropriate State Medicaid/Medicare task force meetings, or other collaborative meetings as requested.
• Identifies opportunities for improvement through the investigative and audit processes and provide recommendations for system enhancement in order to augment investigative outcomes and performance.
• Within formal project management methodologies, plans program timeline and milestones.
• Identifies and resolves issues related to the program.
• Directs the workflow of SIU, represents SIU and answers auditor's questions through maintained knowledge of day-to-day operations and government guidelines.
• Works closely with state and federal program integrity organizations, and the NBI MEDIC or other agencies in properly representing Mount Carmel Health Plan.
• Participates in the oversight, detection, investigation and ongoing monitoring of member and/or provider FWA through focused investigation, data analysis, medical record reviews, onsite and desk audits.
• Performs objective desk and onsite medical record audits to verify if services were supported by documentation, to determine if services were appropriately administered, and/or to validate coding/billing accuracy.
• Coordinates with various internal customers (e.g., Provider Services, Contracting and Credentialing, Healthcare Services, Member Services, Claims, Quality, Compliance, Pharmacy, etc.) to gather documentation pertinent to investigations, as well as make appropriate interdepartmental referrals as indicated by investigations completed.
• Develops provider education on appropriate practices (e.g., coding) as appropriate based on national or local guidelines, contractual, and/or regulatory requirements as a result of investigative findings.
• Assists in member education/prevention/outreach regarding FWA schemes, trends discovered during investigative steps.
• Perform other duties as assigned.

What we're looking for:

• Education: Bachelor's Degree.
• Licensure / Certification: CPC certification highly desired. Certified Fraud Examiner (CFE) or Accredited Health Care Fraud Investigator (AHFI) also preferred.
• Experience: Strong leadership and effective written and verbal communication skills.
• Strong leadership and effective written and verbal communication skills.
• Preferred minimum of five to ten (5-10) years experience in an insurance environment, coding experience and health care industry knowledge.
• Minimum of five (5) years experience conducting medical reviews and coding/billing audits involving professional and faciliy-based services.
• Knowledge of Medicare regulations and Medicare Advantage plan structure is required.
• Ability to effectively handle cases of FWA in a discreet, confidential, and professional manner.
• Demonstrates broad base knowledge and measurement in efficiency and effectiveness of FWA.

Mount Carmel and all its affiliates are proud to be equal opportunity employers. We do not discriminate on the basis of race, gender, religion, physical disability or any other classification protected under local, state or federal law.

Our Commitment to Diversity and Inclusion
 

Trinity Health is a family of 115,000 colleagues and nearly 26,000 physicians and clinicians across 25 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions.

Our dedication to diversity includes a unified workforce (through training and education, recruitment, retention, and development), commitment and accountability, communication, community partnerships, and supplier diversity.