Full Job Description
SHIFT: Day Job
Your Talent. Our Vision. At Anthem, Inc., it’s a powerful combination, and the foundation upon which we’re creating greater access to care for our members, greater value for our customers, and greater health for our communities. Join us and together we will drive the future of health care.
This is an exceptional opportunity to do innovative work that means more to you and those we serve at one of America’s leading health care companies and a Fortune Top 50 Company.
Program Integrity Manager
Location(s): Pittsburgh, PA
The Program Integrity Manager is responsible for overseeing investigations of possible fraud activities and giving feedback to investigations staff. Ensures the accuracy of claims payment through the management of a robust process for prevention, detection, and correction of billing, payment and membership errors. Works with health plan leaders and customers, oversees the monitoring and enforcement of the fraud, waste, and abuse compliance program to prevent and detect potential fraud, waste, and abuse activities pursuant to state and federal rules and regulations. Primary duties may include, but are not limited to:
Has detailed technical knowledge of the Pennsylvania HealthChoices program and fraud investigation.
Monitors quality and recommends alternate solutions to problems.
Anticipates the effect of changes in the business environment on future fraud, waste, and abuse activities.
Evaluates regulatory compliance and Health Care Reform changes to determine potential impact.
Evaluates provider activities to assist in the detection of fraud, waste and abuse activities.
Monitors provisions of the compliance plan, including fraud, waste, and abuse policies and procedures, investigates unusual incidents and implements corective action plans.
Develops and analyzes monthly reports.
Develops project plans and oversees project execution, issue management and progress reporting.
Develops processes to support early detection of systemic issues causing operational inefficiencies.
Requires a BA/BS in Business, Engineering, Nursing, Finance, or Healthcare Administration; 5 years of related work experience, including 2 years of leadership experience; or any combination of education and experience, which would provide and equivalent background. MBA preferred.
Accredited Health Care Fraud Investigator (AHFI) and Certified Fraud Examiner (CFE) certifications preferred.
Some Local Travel Required (20%)
We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.
Anthem, Inc. has been named as a Fortune 100 Best Companies to Work For®, is ranked as one of the 2020 World’s Most Admired Companies among health insurers by Fortune magazine, and a 2020 America’s Best Employers for Diversity by Forbes. To learn more about our company and apply, please visit us at careers.antheminc.com. An Equal Opportunity Employer/Disability/Veteran. Anthem promotes the delivery of services in a culturally competent manner and considers cultural competency when evaluating applicants for all Anthem positions.