Who We Are

Point32Health is a leading not-for-profit health and well-being organization dedicated to delivering high-quality, affordable healthcare. Serving nearly 2 million members, Point32Health builds on the legacy of Harvard Pilgrim Health Care and Tufts Health Plan to provide access to care and empower healthier lives for everyone. Our culture revolves around being a community of care and having shared values that guide our behaviors and decisions. We’ve had a long-standing commitment to inclusion and equal healthcare access and outcomes, regardless of background; it’s at the core of who we are. We value the rich mix of backgrounds, perspectives, and experiences of all of our colleagues, which helps us to provide service with empathy and better understand and meet the needs of the communities where we serve, live, and work.

We enjoy the important work we do every day in service to our members, partners, colleagues and communities. Learn more about who we are at Point32Health.

Job Summary

Operating within the Special Investigations Unit (\"SIU\") of the Legal Department, the Point32Health Manager, Prevention & Recovery manages the investigative team responsible for conducting an array of prepayment review activities encompassing all lines of business and multiple provider types. In addition, the manager will hire and train Investigators to perform prepayment reviews, performs complex data analysis, and assists the SIU Director in developing and implementing strategic anti–fraud initiatives.

Job Description

Key Responsibilities/Duties – what you will be doing (top five):

• Manage team of investigators conducting high-volume provider fraud and abuse related investigations, pre-payment prevention activities, and post-payment recovery activities. Management activities include tracking investigator caseload, prompting investigators when necessary, providing support and assistance in developing investigative plans, evaluating investigator performance, and conducting performance reviews, and meeting with investigators and the FPRU Director to set goals and create development plans.
• Manage, and when appropriate, serve as lead investigator in complex provider fraud investigations including issues of upcoding, services not rendered, excessive or duplicate billing, and billing for investigational on non-covered services.
• Liaise with the FPRU’s 2-3 investigator member fraud team to coordinate investigative efforts.
• Work closely with the Director of the FPRU (“Director”) to review fraud referrals, fraud trends, and data mining results to assign and prioritize provider fraud investigations.
• Conduct complex data analysis using internal claims analysis tools and vendor data mining tools. Assess and develop additional data collection methods to identify fraud, waste, and abuse.
• Recommend and develop provider fraud investigation strategies, initiatives, goals, work plans, benefit document changes, and departmental education concerning fraud, waste, and abuse.
• Actively educate Point32Health staff outside of the unit and make presentations to specific provider associations, hospitals, and provider groups.
• Manage the provider fraud database.
• Track, document, and maintain accountability for financial analysis, and quarterly reporting of fraud cases. Report results to the director.
• Serve as an FPRU liaison to various internal departments, including Pharmacy, Member Services, and Medical Affairs, risk management, and Sales and Underwriting, and external entities, including employer groups, providers, CMS (NBI MEDIC), EOHHS (Executive Office of Health and Human Services), the Office of the Attorney General, and the Insurance Fraud Bureau.
• Other projects and duties as assigned.

Qualifications – what you need to perform the job

Certification and Licensure

• Clinical license (e.g., RN, LICSW), or Coding or Fraud-related Certification (CPC, CFE, AHFI, etc.) strongly preferred.

Education

• Required (minimum): Bachelor’s degree
• Preferred:

Experience

• Required (minimum): 5-10 years of experience investigating health care fraud, or equivalent experience (such as hospital or provider risk management). Strong data analysis skills and experience using claims querying tools such as Cognos and SQL.
• Preferred: Management experience. 5 + years of previous experience in commercial or managed care environment strongly. Regulatory or law enforcement experience a plus.

Skill Requirements

• Computer literacy is mandatory
• Excellent writing and analytical skills. Excellent investigative skills
• Excellent communication skills; must be able to communicate effectively with all levels of the organization and external customers. Excellent organizational skills. Familiarity with claims data querying systems.
• Total accuracy and attention to detail. Sound judgment and decision-making skills.
• Ability to successfully manage in a complex environment.
• Ability to manage and be directly responsible for multiple projects running simultaneously.
• Coaching, mentoring and management skills. Relationship building skills required.
• Must be able to work cooperatively in a team environment. Sense of humor.

Working Conditions and Additional Requirements (include special requirements, e.g., lifting, travel):

• Must be able to work under normal office conditions and work from home as required.
• Work may require simultaneous use of a telephone/headset and PC/keyboard and sitting for extended durations.
• May be required to work additional hours beyond standard work schedule.
• Must be able to travel to courthouses, law enforcement offices and other locations both within and outside Massachusetts.

Disclaimer

The above statements are intended to describe the general nature and level of work being performed by employees assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of employees assigned to this position. Management retains the discretion to add to or change the duties of the position at any time.

Compensation & Total Rewards Overview

As part of our comprehensive total rewards program, colleagues are also eligible for variable pay. Eligibility for any bonus, commission, benefits, or any other form of compensation and benefits remains in the Company's sole discretion and may be modified at the Company’s sole discretion, consistent with the law.

Point32Health offers their Colleagues a competitive and comprehensive total rewards package which currently includes:

• Medical, dental and vision coverage

• Retirement plans

• Paid time off

• Employer-paid life and disability insurance with additional buy-up coverage options

• Tuition program

• Well-being benefits

• Full suite of benefits to support career development, individual & family health, and financial health

For more details on our total rewards programs, visit https://www.point32health.org/careers/benefits/

We welcome all
All applicants are welcome and will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.

Scam Alert: Point32Health has recently become aware of job posting scams where unauthorized individuals posing as Point32Health recruiters have placed job advertisements and reached out to potential candidates. These advertisements or individuals may ask the applicant to make a payment. Point32Health would never ask an applicant to make a payment related to a job application or job offer, or to pay for workplace equipment. If you have any concerns about the legitimacy of a job posting or recruiting contact, you may contact TA_operations@point32health.org

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