Anthem Mgr I Investigations - Remote (Norfolk, VA Preferred) - PS5580 in Rockville, Maryland

Mgr I Investigations - Remote (Norfolk, VA Preferred) - PS5580


Location: United States

Field: Fraud

Requisition #: PS5580

Post Date: 6 days ago

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 benefits companies and a Fortune Top 50 Company.

The Manager I Investigations is responsible for directing all activities of the Fraud Investigations Unit in assigned territory.

Primary duties may include, but are not limited to:

  • Supervises and coordinates the investigations of alleged Medicare fraud.

  • Coordinates the analysis of provider utilization patterns and trends and of provider billing and financial data an supervises the case inventory to include monitoring of aging and priority.

  • Oversees the integration of various computer systems in the Unit, to include monitoring of aging and priority. Coordinates the review of documentation to ensure validity and applicability of data, the preparation of written summaries of the investigations, and the development of cases to be referred to the Office of the Inspector General (OIG).

  • Continually communicates with CMS, OIG, and Department of Justice regarding current fraud trends, current case issues, and current analyses and training opportunities.

  • Actively participates in ISO Certification renewal, proposals and transitions of additional PSC business and serves as a lead for specified functions.

  • Keeps abreast of changes in Medicare benefits, policies and regulations and in CMS performance standards and assists management in the interpretation of Medicare policies and procedures.

  • Works in conjunction with the Quality Management Supervisor to maintain a quality assurance and improvement program that is in accordance with the ISO Quality Management System.

  • Hires, trains, coaches, counsels, and evaluates performance of direct reports.

  • Requires BA/BS in business or nursing; 5+ years in investigations ; or any combination of education and experience, which would provide an equivalent background.

  • The Government requires that personnel working on Medicare Fraud investigations are U.S. Citizens.

  • Certified Professional Coder (CPC) required

  • Prior Management experience

  • Experience with Microsoft Access and SQL

  • Detail oriented

Location: Norfolk, VA office preferred

Other Locations Considered: Remote

Anthem, Inc. is ranked as one of America’s Most Admired Companies among health insurers by Fortune magazine and is a 2017 DiversityInc magazine Top 50 Company for Diversity. To learn more about our company and apply, please visit us at EOE. M/F/Disability/Veteran.