4 days old

Watson Health - Audit and Investigation Project Manager

Des Moines, IA 50309
  • Job Code
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Your Role and Responsibilities
Location: You will be working on-site at the client's downtown location in Des Moines.

The Audit and Investigation Project Manager is responsible for oversight of two key components of the Program Integrity contract, providing overall project management for IBM Watson Healths Audits and Investigations team supporting Iowas Medicaid Enterprise, and directing the case disposition team to achieve objectives. This position will organize and oversee the workload of these two functions and will coordinate activities with audit subcontractor(s) and/or managed care organizations special investigation units (SIUs) and other stakeholders where appropriate. The Audit and Investigation Project Manager is responsible for the timely documentation, monitoring/creating performance measures of staff, as well as resolution and outcome of each fraud and abuse case.

Primary Responsibilities

Develops policies, procedures,
processes, and workflows to support the Case Disposition Process.
Sets priorities for provider audits and investigations/case disposition workload.
Recommends goals and objectives for the Audits and Investigations Team.
Responsible for agenda preparation, facilitation and compiling minutes for standing meetings with stakeholders.
Provides input into the configuration, testing, implementation and ongoing operations of the I-sight case management tracking system.
Review of all letter drafts and associated documents for initial audit findings, final audit findings, responses to requests for review and reconsideration of audit finding and any letters drafted to address unique circumstances that present themselves in day to day audit activities. Obtains client/appropriate staff approval of letters and other communications that will be sent to provider offices where applicable.
Responds to provider inquiries that have been escalated from the Audits and Investigations Team.
Ensures that there is a fair and equitable appeals process in place for providers.
Supports client (Iowa Medicaid Enterprise) during appealed cases.
Identifies areas for provider education and works with the functional teams to develop appropriate materials.
Coordinates audit and investigation activities with other functional teams as needed.
Collaborates with the Customer to design effective processes for the recovery of overpayments.
Ensures that subcontractors are performing consistent with contract expectations and addresses any issues that may arise.
Designs management reports and metrics that will demonstrate Return on Investment (ROI) to the Customer.
Monitors budget and resource needs in conjunction with the Project Director.
Establishes performance measures for staff, as well as monitors and intervenes as necessary.
Manages audits and investigations team to include, but not limited to, team collaboration, ongoing fraud, waste, and abuse education and ensuring staff meets contractual requirements and deadlines.

Coordination Related Tasks
Participate in MIC calls and offer status updates as needed.
Maintain letter templates used in day to day SUR operations and incorporate changes as indicated by the client or as business needs arise. Coordinate with the appropriate client staff to verify review and approval by legal counsel.
Participate in internal status updates with contractor management staff. Participate in status meetings between sub-contractors and client staff.
Assist with review of subcontractor letters and documents as needed prior to submission to the client.
Review and approve algorithm recovery status report and letter statistics prior to submission to the client.
Design, develop, review and deliver SUR and other reports to the state to support the efficient operation of the team and meet contractual requirements.
Research claims payment policies, provider manual, provider communications, regulations, coding guidelines and federal legislation as related to SUR audit activities.
Collaborate with external stakeholders by participation in meetings with the Medicaid Fraud Control Unit (MFCU) and the US Attorney.

Case Management System
Assist with review and provide input for compilation of I-sight case management system requirements as needed. Meet with client to discuss and review Business Design documents for audit and case disposition related system changes.
Manage and monitor I-sight system reports to ensure compliance with contractual requirements.
Monitor documentation of investigators to ensure quality and compliance with contractual requirements.

Collaborate with data analytics team to produce and carry out algorithm findings.
Provide input on contract goals and achievements related to audit and investigation activities for development of year end reporting.
Coordinate cost avoidance activities resulting from opportunities identified by investigators for policy recommendations to the state

Required Professional and Technical Expertise
At least 3 years experience in program integrity, and/or fraud, waste, and abuse provider audits
Multiple years of previous people management experience
Experience developing policies, procedures,
processes, and workflows.
Prior experience with health care claims and provider relations
Excellent oral and written communication skills and outstanding presentation skills.
Ability to motivate and inspire others
Computer literate, with experience in Word, Excel, PowerPoint and workflow solutions

Preferred Professional and Technical Expertise
8+ years experience in program integrity, and/or fraud, waste, and abuse provider audits
Bachelors degree or higher
in a health-related field
with Medicaid preferred

About Business Unit
IBM Watson Health is pioneering a new partnership between humanity and technology with the goal of transforming global health and revolutionizing many aspects of the medical and pharmaceutical industries, as well as government sectors. We aspire to improve lives and give hope by delivering innovation to address the worlds most pressing health challenges through data and artificial intelligence insights.

Your Life @ IBM
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Maybe you want to get involved in work that really changes the world? What about somewhere with incredible and diverse career and development opportunities where you can truly discover your passion? Are you looking for a culture of openness, collaboration and trust where everyone has a voice? What about all of these? If so, then IBM could be your next career challenge. Join us, not to do something better, but to attempt things you never thought possible.

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About IBM
IBMs greatest invention is the IBMer. We believe that progress is made through progressive thinking, progressive leadership, progressive policy and progressive action. IBMers believe that the application of intelligence, reason and science can improve business, society and the human condition. Restlessly reinventing since 1911, we are the largest technology and consulting employer in the world, with more than 380,000 IBMers serving clients in 170 countries.

Location Statement
For additional information about location requirements, please discuss with the recruiter following submission of your application.

Being You @ IBM
IBM is committed to creating a diverse environment and is proud to be an equal opportunity employer. All qualified applicants 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. IBM is also committed to compliance with all fair employment practices regarding citizenship and immigration status.



  • Computers Software and Hardware
Posted: 2019-08-16 Expires: 2019-09-16

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Watson Health - Audit and Investigation Project Manager

Des Moines, IA 50309

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