FWA Senior Auditor

Requisition ID:875818

Position:Full-Time

Total Rewards:Benefits/Incentive Information

There's more to EyeMed than meets the eye. EyeMed is the fastest growing managed vision benefits company in the country with consistent double-digit membership growth! Through our commitment to innovation, we're reimagining the way employers and their employees think about vision care. We want them to see life to the fullest and experience more of what's best, not more of the same. And if what's best hasn't been done yet, it's our exceptional and passionate employees driving this change. But, our passion for vision isn't just about vision insurance benefits. Our employees are proud to support and participate in life-altering global and local missions through our partnership with OneSight, a leading not-for-profit organization with a 100% focus on eradicating the world's vision crisis.

Your family says a lot about who you are. EyeMed is a key member of the Luxottica family of companies, global leaders in the design, manufacture and distribution of fashion, luxury and sports eyewear. In North America, Luxottica is the home to global brands Ray-Ban, Oakley and many top fashion house brands. Our leading retail brands include LensCrafters, Sunglass Hut, Pearle Vision, and Target Optical.

If you're passionate about driving innovation and change and interested in a career in the optical and insurance industry, EyeMed wants to start the conversation and help provide you a growth-focused opportunity with America's fastest growing vision benefits company.

GENERAL FUNCTION

EyeMed Vision Care's Special Investigation Unit is responsible for identifying, preventing insurance fraud and recovering funds lost to insurance fraud, waste and abuse. The SIU Senior Auditor leads the review, analysis and investigation of providers and claims to confirm contract compliance and/or to suspected fraud, waste or abuse.

MAJOR DUTIES AND RESPONSIBILITIES

• Conducts timely and thorough investigations of providers and managed vision care claims to confirm claim validity or to disposition allegations of suspected fraud, waste, abuse and/or billing errors.
• Manages a caseload of investigations including claim analysis, letter generation, provider outreach and case summary & reporting.
• Presents audit findings of suspected fraud cases to EyeMed's Special Investigation Committee and leads committee discussion regarding recommended corrective action.
• Issues and tracks corrective action plans and re-audits based on audit results.
• Acts as a liaison between the operational leadership, Quality Assurance, Compliance, Legal, Account Management and Finance to ensure accurate reporting to impacted client Special Investigation Units, Medicaid fraud units, and/or other regulatory/governmental agencies.
• Identifies opportunities with recommendations for process improvements necessary to facilitate department functions.
• Conducts ongoing analysis of data and trends to seek out root cause drivers and identify opportunities to refine and improve fraud, waste & abuse monitoring and recovery
• Participates in industry training activities to stay informed on regulatory compliance changes, broader industry trends, and health plan partner priorities
• Provides ongoing monitoring and reporting regarding performance against KPIs

BASIC QUALIFICATIONS

• Bachelor's Degree or equivalent work experience
• 3+ years of work experience
• Strong critical thinking skills with emphasis on root-cause analysis
• High level of professionalism and ability to deal with sensitive information
• Excellent written and oral communication skills
• Proficient in all MS Office applications and advanced skills in MS Excel
• Positive influencing and collaboration skills at all levels

PREFERRED QUALIFICATIONS

• Experience in an audit or investigative role
• Experience in a managed health care setting
• Claims processing or medical/vision benefits and product experience
• Experience working with managed care claims or similar transactional data structures
• Demonstrated ability to learn new systems

Employee pay is determined by multiple factors, including geography, experience, qualifications, skills and local minimum wage requirements. In addition, you may also be offered a competitive bonus and/or commission plan, which complements a first-class total rewards package. Benefits may include health care, retirement savings, paid time off/vacation, and various employee discounts.

Upon request and consistent with applicable laws, EssilorLuxottica will provide reasonable accommodations to individuals with disabilities who need assistance in the application and hiring process. To request a reasonable accommodation, please call the EssilorLuxottica SpeakUp Hotline at 844-303-0229 (be sure to provide your name and contact information so that we may follow up in a timely manner) or email HRCompliance@luxotticaretail.com.

We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, gender, national origin, social origin, social condition, being perceived as a victim of domestic violence, sexual aggression or stalking, religion, age, disability, sexual orientation, gender identity or expression, citizenship, ancestry, veteran or military status, marital status, pregnancy (including unlawful discrimination on the basis of a legally protected pregnancy or maternity leave), genetic information or any other characteristics protected by law. Native Americans in the US receive preference in accordance with Tribal Law.