I have over 10 years of experience in managing payment integrity programs, primarily in the healthcare sector. My role involved overseeing the development and implementation of strategies to identify and resolve payment discrepancies, ensuring compliance with regulatory standards. I led cross-functional teams to analyze payment data, implement fraud detection systems, and optimize payment processes, resulting in significant cost savings and improved operational efficiency.

Balancing cost containment with high-quality care involves a strategic approach that prioritizes data-driven decision-making. I ensure that all cost-saving measures are implemented without compromising patient care by closely monitoring outcomes and engaging with clinical teams to understand the impact of changes. Regular audits and feedback loops are essential to maintain this balance, ensuring that any adjustments are made with both financial and clinical considerations in mind.

To reduce fraud, waste, and abuse, I have implemented a multi-layered strategy that includes advanced analytics, regular audits, and employee training. By leveraging data analytics, we can identify patterns and anomalies that may indicate fraudulent activity. Regular audits help ensure compliance with policies and procedures, while comprehensive training programs educate staff on recognizing and reporting potential issues. These strategies collectively contribute to a robust payment integrity framework.

Effective communication and collaboration are achieved through regular meetings, clear communication channels, and a shared vision. I facilitate cross-departmental meetings to ensure alignment on goals and objectives, and I encourage open dialogue to address any concerns or challenges. By fostering a culture of transparency and collaboration, we can ensure that all departments are working towards the same objectives, ultimately enhancing the overall effectiveness of the payment integrity program.

In a previous role, I navigated a complex regulatory environment by staying abreast of regulatory changes and ensuring that our payment integrity program was fully compliant. I worked closely with legal and compliance teams to interpret new regulations and implement necessary changes. This involved conducting impact assessments, updating policies and procedures, and providing training to staff. By proactively addressing regulatory requirements, we were able to maintain compliance while minimizing disruptions to our operations.