PERSOLKELLY’s Snapshot
An amazing opportunity to join a global insurance company as a Team Lead for Fraud Investigations.
Company Profile
Our client company is a global health services company dedicated to improving the health, well-being, and peace of mind of their clients. To date, they have more than 180 million customer and patient relationships in more than 30 countries and jurisdictions.
Role Overview
As a Quality Review & Audit Senior Supervisor within the Payment Integrity FWA Team you will be directly supporting the firm’s affordability commitment within their international's business. This role is responsible for managing a team accountable for detecting and recovering FWA payments, creating solutions to prevent claims overpayment and future spend monitoring. He/ She will work closely with other team members, Network, Medical Economics, Data Analytics, Claims Operations, Clinical partners, Product and International Markets Special Investigation Unit.
Responsibilities
- Lead the Quality Assurance and Audit team who are responsible for identifying and preventing fraudulent, wasteful and abusive expenses within firm’s International Business Market ensuring team targets and KPIs are met.
- Works closely with PI FWA senior management to understand strategy and is responsible for executing departmental plans and priorities.
- Accountable for managing internal stakeholder relationships.
- Coach and support all PI FWA teams to monitor and identify non-compliance in billing and claims payment activity within the international markets.
- Ensure department KPIs are met through effective monitoring and reporting mechanisms; ensure PI savings are tracked and reported accurately.
- Executes strategic initiatives, plans, and goals in alignment with department KPIs and financial targets.
- Effectively use business intelligence and data analytics to monitor PI FWA regional claim patterns and identify opportunities for PI intervention and liaises with the Global Delivery Services Analytics Manager to develop FWA rulesets.
- Ensures payment integrity processes are in compliance with legal, regulatory and contractual requirements.
- Assess work demand against capacity to ensure optimum claim referrals across all referral routes; create solutions, drive execution and ensure timeliness and accuracy of PI claims review process, loss prevention and recovery activity.
- Instils work culture of continuous process improvement, innovation, and quality.
- Oversee departmental personnel matters; evaluating staff performance and conducting performance appraisals for all direct reports. Ensure adherence to company practices and procedures.
- You will perform and coordinate a variety of pre and post-pay focused cost avoidance activities including identifying and investigating suspected aberrant behaviour, data-mining to reveal FWA trends and patterns and conducting provider onsite and offsite audits.
- Perform verification of services and charges and negotiate with providers contracted by firm or out-of-Network providers.
- Recommends changes in policy and procedures in order to mitigate risk and participates in projects to improve business protocols.
- Provides input into workforce planning and recruitment activities and addresses resource and operational challenges.
- Working closely with other departments to ensure Payment Integrity activities do not have an unnecessary negative impact on our customers.
Requirements
- Experience of leading operational teams. You should enjoy working in a team of high performers, who hold each other accountable to perform to their very best.
- Minimum of 5 years of health insurance or international health care provider experience.
- Knowledge of claims coding, regulatory rules and medical policy.
- Medical/ paramedical qualification is a definite plus.
- Passive knowledge of medical terminology and treatment modalities.
- Critical mind-set with ability to identify cost containment opportunities.
- Strong reporting and analytical skills with ability to create and improve reporting packs and methodologies with some support.
- An experience with data analytics tool(s) is a strong asset.
- Excellent verbal and written communication, interpersonal and negotiation skills.
- Ability to balance multiple priorities at once and deliver on tight timelines.
- Flexibility to work with global teams and varying time zones effectively.
- Confidence to deal with internal stakeholders and ability to work with a cross functional team.
- Strong organization skills with the ability to juggle priorities and work under pressure to meet tight deadlines.
- Fluency in foreign languages in addition to fluent English is a strong plus.
Action Now
Please send your resume to Dal Gill via email dal_gill@persolkelly.com and give him a call at +852 2281 0073 for a confidential discussion about this role and other exciting opportunities.
