Manager Network Integrity
Blue Cross and Blue Shield of Alabama - Birmingham, AL

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Department Overview The Health Management Division provides valuable health and wellness services to help people maximize their health and quality of life. Health Management is one of the most critical issues Blue Cross and Blue Shield of Alabama faces in fulfilling its responsibility to be a superior administrator of health care benefits. Our goal is to provide the highest quality benefits and services while we effectively control health care costs. General Responsibilities This position is responsible for the daily management of operations in the Network Integrity area.

The Unit is responsible for the detection, case development and remediation in cases of suspected fraud and abuse involving commercial and government products lines. The scope of accountability includes fraud and abuse involving providers, members and employer groups. Additional accountability includes coordination of fraud and abuse efforts with external business partners such as Prime and delegated mental health networks. Fraud, waste and abuse activities encompass management of cases both within the Alabama service area, as well as cases outside the primary service area which require coordination with Blue's plans nationwide, the national FEP special investigations unit as well as multiple regulatory/ investigative agencies across the country.

International fraud and abuse is also inclusive of the scope when member services are rendered out of the country.

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