This is a hybrid role that requires a weekly onsite presence to Assembly Row in Somerville.



Mass General Brigham Health Plan is an exciting place to be within the healthcare industry. As a member of Mass General Brigham, we are on the forefront of transformation with one of the world's leading integrated healthcare systems. Together, we are providing our members with innovative solutions centered on their health needs to expand access to seamless and affordable care and coverage.


Our work centers on creating an exceptional member experience - a commitment that starts with our employees. Working with some of the most accomplished professionals in healthcare today, our employees have opportunities to learn and contribute expertise within a consciously inclusive environment where diversity is celebrated.


We are pleased to offer competitive salaries, and a benefits package with flexible work options, career growth opportunities, and much more.



Principal Duties and Responsibilities



• Responsible for conducting confidential investigations of suspected fraud, waste & abuse (FWA) involving medical providers, plan members or other entities or individuals. Investigative activities include, but are not limited to: data analysis, public records research, document review, and interviewing.
• Performs case research to include the review, interpretation and application of payment policies, medical policies, provider manuals, benefit documents, national or local coverage determinations and other applicable clinical practice parameters, regulations or guidance pertaining to the submission of claims to health insurance plans.
• Obtains investigative evidence by requesting medical and administrative documents and by conducting interviews of providers, members or other associated parties.
• Analyzes and interprets multiple sources of data including health insurance claims, financial transaction information, contract configurations and other materials.
• Establishes strong contacts within the organization to obtain materials relevant to FWA investigations and to ensure appropriate escalations, when required.
• Is an expert report writer with the ability to create timely documentation including investigative plans, case summaries, and interview reports.
• May be required to present to internal stakeholders or to testify in civil or criminal court proceedings.
• Stays up to date with industry trends, including those pertaining to prevailing FWA schemes.
• Maintains adherence to all Medicare and Medicaid requirements and obligations pertaining to the performance and reporting of investigative activity.
• Hold self and others accountable to meet commitments.
• Ensure diversity, equity, and inclusion are integrated as a guiding principle.
• Persist in accomplishing objectives to consistently achieve results despite any obstacles and setbacks that arise.
• Build strong relationships and infrastructures that designate Mass General Brigham Health Plan as a people-first organization.
• Other duties as assigned with or without accommodation.



Qualifications

Qualifications:



• 5-7 years of experience conducting FWA investigations, preferably with experience investigating claims submitted to Medicare Advantage and/or Medicaid ACO/MCO plans.
• Superior analytical skills and expertise utilizing Microsoft Excel and/or Microsoft Access (SQL or other coding abilities a strong plus).
• Demonstrated writing proficiency and experience conducting document reviews.
• Bachelor's degree required or the equivalent combination of training and experience.
• Certified Fraud Examiner (CFE) or Accredited Health Care Fraud Investigator (AHFI) preferred.



Skills/Abilities/Competencies:



• Demonstrate Mass General Brigham Health Plans core brand principles of always listening, challenging conventions, and providing value.
• Bring fresh ideas forward by listening to and working with employees and the people we serve.
• Respect the talent and unique contributions of every individual and treat all people in a fair and equitable manner.
• Strong, demonstrated track record of an ability to execute on time, on budget, and on scope.
• Strong aptitude for technology-based solutions.
• Ability to inject energy, when and where it's needed.
• Current in healthcare trends.
• Demonstrated forward, visionary thinking; ability to see "what is" and envision "what could be."
• Ability to develop, introduce, defend, and gain support for a new ideas and approaches.
• Excellent leadership skills and leadership track record.
• Ability to translate and communicate complex topics in a variety of forums, tailoring communications to effectively fit and influence the targeted audience, strong executive presence, presentation, and communication skills. Strong verbal, active listening, and written communication skills required.
• Ability to view the long-range trends and cycles of the business and industry and see the "big picture."
• Ability to apply a variety of strategic frameworks to analyze problems and to guide and develop solutions.
• Ability to challenge the status quo and drive innovative thinking and the capability to successfully implement strategy.
• Excellent interpersonal skills, including the ability to influence others at all levels of an organization.
• Strong EQ; exercises self-awareness; monitors impact on others; is receptive to and seeks out feedback; uses self-discipline to adjust to feedback.
• Unquestionable integrity.


Supervisory Responsibilities:



• No Supervisory Responsibilities



Fiscal Responsibility:



• No direct budgetary responsibility
• Demonstrates fiscal responsibility by effectively using Mass General Brigham Health Plan resources



Working Conditions:



• Normal office working conditions.
• Remote position with occasional need to go into the office for meetings or trainings.



EEO Statement

Mass General Brigham is an Equal Opportunity Employer. By embracing diverse skills, perspectives and ideas, we choose to lead. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment.