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Director of Claims Integrity/Fraud, Waste and Abuse – Remote

New Directions Behavioral Health

This is a Full-time position in New York, NY posted December 14, 2021.

For more than 25 years, New Directions has been helping its members become the best versions of themselves.

We know that mental health is a crucial part of overall health and well-being.

Through a suite of behavioral health services, an Employee Assistance Program and Student Assistance Programs, we serve more than 16 million people across the nation by improving their access to quality behavioral healthcare.

You can help us change lives by starting with your own.

We’re looking for bright, passionate and ambitious people to help be the difference that makes a difference.

Role and Responsibilities:

  • Ensure Claims Integrity operations are managed effectively, deliver results, and promote a model of operational excellence and continuous improvement.
  • Drive the strategic leadership, guidance, and tactical direction for provider and facility fraud operations; providing strategic direction and management of all daily operational functions.
  • Ensure consistency of approach related to analysis techniques, key findings, and the development of reporting and recoupment opportunities, and demonstrate that consistency through the creation and maintenance of representative policies and procedures.
  • Ensure best in class fraud processes, infrastructure, and tools are utilized to accurately identify and manage fraud risk.

    Collaborate with FWA related software vendor to improve algorithmic behavioral health related FWA detection. 

  • Build internal fraud awareness, education, and alert notification processes.

    Participate in presentations to the Senior Leadership Team and Board of Directors as requested.

  • Engage effectively with internal and external stakeholders to identify new and emerging fraud schemes and influence the development and delivery of solutions to maximize client savings.

    Demonstrate department value in RFPs, RFIs, and other sales activities via oversight of Claims Integrity related sales materials and in-person presentations. 

  • Analyze, identify, & implement new approaches and methods of advanced analytics to target the department’s need to identify suspicious claims, fraud case targets, and other types of overpayments.
  • Provide executive level consultation and guidance to internal departments and health plan partners regarding behavioral health billing and payment questions. 
  • Act as a Company subject matter expert in corporate coding and payment requirements / impact, provider and facility billing and coding requirements, and state licensure requirements.
  • Develop and deliver on assigned business objectives i.e.

    growth, client satisfaction, quality and compliance metrics, operational and financial measures, and others as appropriate.

  • Provider oversight to Claims Integrity Department to ensure specified team performance goals are met.
  • Supports the Compliance Officer in communicating the results of audits and consulting projects via written reports and oral presentations.
  • This list of duties and responsibilities is not intended to be all-inclusive and can be expanded to include other duties or responsibilities as deemed necessary.

Required Qualifications:

  • Bachelor’s Degree or equivalent certification in a related medical/health care field or in fields such as business, finance, accounting or criminal justice.
  • Experience in developing and implementing audit and/or anti-fraud plans, policies and procedures, training materials, workflow diagrams, and other similar documentation.
  • Management experience that clearly demonstrates leadership.
  • 7+ years of experience in professional audit and/or investigative experience in health care, insurance, law enforcement, risk management, or a related area.
  • 7+ year’s healthcare/managed care claims, reimbursement, contracting and/or analytics experience.
  • Proficient with all healthcare coding (CPT, HCPCS, DRG, ICD-10 & Revenue Codes) 
  • Proficient with data analysis and data mining for purposes of fraud detection
  • Entrepreneurial self-starter who take ownership of projects, processes, work product, and results, and looks to define success based on performance-based goal attainment. 
  • Proficient in Microsoft products, especially Excel, Word and SQL

Preferred Qualifications:

  • Behavioral Health related provider and facility practice audit related experience.
  • Demonstrated experience in successful overpayment recovery because of an oversight or FWA audit.
  • Experience building a behavioral health related fraud, waste, and abuse audit function or department at a health plan, payor, TPA, benefits administrator, or similar organization.
  • Experience building and planning an annual work plan/or strategic initiatives and corresponding budget for a department or segment of an organization.
  • 7+ years of Management Experience.
  • Master’s Degree or equivalent certification in a related medical/health care field or in fields such as business, finance, accounting or criminal justice; or, Master’s Degree or equivalent certification in behavioral health field and has a current, unrestricted state license to practice as a Social Worker, Marriage and Family Therapist, Professional Counselor, Clinical Psychologist or Registered Nurse.
  • Certified Professional Coder (CPC) or equivalent.
  • Accredited Healthcare Fraud Investigator, Certified Fraud Examiner, Certified Insurance Fraud Investigator, Certified Public Accountant, Certified Internal Auditor, Certified Compliance Professional, or other similar licensure/certification
  • Experience presenting to diverse audiences including Senior Leadership (CEO, CFO, CMO, etc.) or Boards of Directors.

FLSA Status:

  • Exempt

Why work for NDBH?
Vibrant, positive culture

Caring isn’t just our job, it’s our culture.

Because we believe a healthy lifestyle starts with a healthy work setting, we take great pride in fostering a friendly, caring and inspiring workplace.

Community involvement

New Directions has a service program that supports a wide range of causes annually.

Employees have the chance to give to those in need and volunteer through company-sponsored volunteered time off.

Competitive benefits

Optimal health is our mission.

That’s why we offer a robust benefit package that includes medical, dental, vision and life insurance plans.

Other benefits include a 401(k) Retirement Program with company contributions, generous PTO, an Employee Assistance Program (EAP), Volunteer Time Off, BetterHelp, and tuition and CEU/License reimbursements.

New Directions Behavioral Health, LLC is an equal opportunity employer.

Qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, citizenship, sex, sexual orientation, gender identity, veteran’s status, age or disability.

Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities

The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant.

However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor’s legal duty to furnish information.