Fraud Waste and Abuse Operations Specialist

Fraud Waste and Abuse Operations Specialist

Full-time Remote Employment

Who We Are:

Constellation Quality Health is a non-profit health care quality consultancy and QIO-like Entity certified by Centers for Medicare and Medicaid Services (CMS) founded by physicians in 1983. Headquartered in North Carolinas Research Triangle we offer an array of quality improvement clinical review audit technical and consulting services and solutions to improve care delivery system performance and patient outcomes.

What Youll Do:

We are seeking a Fraud Waste and Abuse Operations Specialist to ensure required contract deliverables are timely and accurate for delivery to Director determine staff needs and requirements and enhance Constellation Quality Healths visibility and credibility with customers stakeholders and the community.

We expect you to:

• Coordinate and execute remote and in-person training sessions for medical/dental providers including maintaining training metrics scheduling attendance and performance for contract reporting and measurement of customer ROI.
• Conduct data analysis using current and upgraded/new technology across both claims and documents to formulate formal reports to law enforcement and external stakeholders for investigations.
• Assist with monitoring team key performance indicators such as productivity schedules volume and accuracy and timeliness of deliverables with ability to reconcile expenses and contain contract costs.
• Assist with instruction preparation implementation and development of new technology tools guidelines and training materials for team members and providers on review.
• Assist Director to maintain contracts cost to stay within budget.
• Provide excellent customer service and assist with identifying and implementing innovative customer solutions; research and resolve provider inquiries and/or complaints related to services provided.
• Assist with the development of team and medical provider training materials and participate in cross-training.
• Assist in the development of program operations manuals and reports (conducting assessments data entry etc. internal reports technical writing for proposals to obtain new business) and in the design preparation and submission of weekly and monthly reports.
• Collaborate and assist as requested by Director with Information Technology (IT) development and workflow implementation for data collection tracking notification and reporting as required.
• Coordinate with managers to conduct independent research to assist with capture reporting and prepare to manage incoming clients as new work is awarded and operational needs arise.

Our requirements for this role:

• Associate degree required in a human services field or five (5) years of related experience may substitute for degree.
• At least two (2) years experience in scheduling programming or managing business operations.
• Experience in medical or dental field with familiarity of documents and processes.
• Supervisory experience and certified professional code or accredited/certified investigator credential preferred.
• Proficiency in Microsoft Suite (Word Excel PowerPoint Outlook PowerBI etc.) web platforms and SharePoint.
• Experience in Quality Improvement and implementation of Corrective Action Plans preferred.
• Excellent communication skills both written and oral.
• Basic understanding of data management and statistics.

Why Constellation Quality Health

We offer a competitive salary and benefits package and a flexible supportive hybrid work environment.

Salary Range: $75000 - $85000 annually

Benefits: Health dental and vision insurance; 401(k) with employer match; paid holidays and PTO.

Equal opportunity employer of protected veterans

Equal opportunity employer of individuals with disabilities

We do not discriminate on the basis of race ancestry color religion sex age marital status sexual orientation gender identity national origin medical condition disability veteran status or any other basis protected by law

Applicants and employees are protected from discrimination based on inquiring about disclosing or discussing compensation or the compensation of other applicants or employees.