Manager of Clinical Review, Program Integrity Solutions

Towson, MD
Feb 01, 2017
Aug 28, 2017
Full Time
General Dynamics Health Solutions is seeking a dynamic Manager to oversee SIU Medical Review operations. Our team supports services provided to healthcare payers for the detection, investigation, and disposition of cases of potential healthcare fraud, waste, and abuse. The scope of these services includes data analysis, prioritization and triaging of workload, selecting random samples, performing pre-pay or post pay medical review, interviewing members and/or providers, conducting onsite and desk audits, calculating overpayments, collecting overpayments, packaging cases for referral to law enforcement, identifying health plan vulnerabilities, recommending administrative actions, developing and delivering provider education programs, developing and delivering health plan internal fraud awareness training programs, consulting on anti-fraud policies & procedures, and measuring/reporting performance metrics. On any given engagement, our team may perform all of the aforementioned services, or we may be contracted to deliver some subset of the total scope. The highest level of objectivity, professionalism, healthcare-specific knowledge, and investigative skills are critical to this leadership position. Our customers will rely on this person's dynamic style and strong communication skills to exceed their expectations.


The right candidate will have experience performing the following:

  • Manage a team of nurses, coders, auditors and other staff in the performance of contract requirements.
  • Conduct reviews of medical records and associated pre-pay or post-pay claims in the course of fraud, waste and abuse investigations or carrying out other program integrity initiatives.
  • Use knowledge of healthcare coding conventions, fraud schemes, and areas of vulnerability, reimbursement methodologies, and relevant laws to help detect suspicious patterns in claims data, provider enrollment data, and other sources.
  • Remain up to date on published fraud cases.
  • Perform proactive data analysis and record review by applying knowledge of coding guidelines, medical procedures, medical policies, Medicare / Medicaid policies, etc.
  • Demonstrate strong communication skills to prepare superior written investigative summaries for submission to customers' staff and healthcare providers.
  • May be the client’s primary point of contact or serve as the lead representing GDHS during customer conversations.
Telecommuting may be considered for the right candidate.

  • Bachelor's Degree in a related discipline required
  • CPC and RN required
  • AHFI and additional coding or clinical certifications preferred
  • All certifications must be current
  • At least 5 years of supervisory or management experience required.
  • Minimum of 8 years of experience in healthcare fraud, waste and abuse reviews (professional, facility).
  • Extensive and thorough knowledge of ICD, CPT, HCPCS, APC, DRG, Revenue Codes, NDCs, and Medicare guidelines (including NCCI).
  • Other certifications a plus: COC, CEMC, AHFI, CHCA, CCS, ART, RHIT, AHFI, CFE.
  • Strong proficiency in MS Office suite.
  • Experience with STARSSolutions Preferred
  • Healthcare claims adjudication experience
  • Strong knowledge of Medicaid regulations and Medicare coverage determinations
  • Dynamic leader with excellent verbal and written communication skills.
  • Strong listening and observation skills.
  • Impeccable work ethic, completely dependable, and proactive; a problem solver and thought leader.
  • Professional representative of GDIT illustrating polish, integrity, and creating trust.
  • Demonstrated ability to provide coaching and performance management of staff.
  • Must have no adverse actions pending or taken against him/her by any State or Federal licensing board or program.
  • Presentation skills to communicate with management and customers.
  • Willingness to travel approximately 20% of the time.
  • Attention to detail and high level of accuracy.
  • Demonstrated organizational and prioritization skills with ability to manage multiple priorities effectively.
  • Innovative; introduces new ideas and processes that improve performance, productivity and benefit integrity.
  • Works independently; collaborates well with peers and customers.

As a trusted systems integrator for more than 50 years, General Dynamics Information Technology provides information technology (IT), systems engineering, professional services and simulation and training to customers in the defense, federal civilian government, health, homeland security, intelligence, state and local government and commercial sectors. With approximately 32,000 professionals worldwide, the company delivers IT enterprise solutions, manages large-scale, mission-critical IT programs and provides mission support services. GDIT is an Equal Opportunity/Affirmative Action Employer - Minorities/Females/Protected Veterans/Individuals with Disabilities.