Also referred to as:
Provider Billing & Fraud Investigation Manager
Requirements and Responsibilities
Provider Billing Investigation Manager manages the team responsible for investigating and auditing healthcare providers to detect and prevent medical billing fraud, waste, and abuse. Reviews medical billing and insurance claims to identify billing anomalies, outliers, and patterns of upcoding, phantom billing, or duplicate charges. Being a Provider Billing Investigation Manager compiles evidence and documents findings in investigative reports. Refers cases of fraud to law enforcement or state regulatory agencies. Additionally, Provider Billing Investigation Manager may take the lead on more complex investigations. Requires a bachelor's degree. Typically reports to a director. The Provider Billing Investigation Manager manages subordinate staff in the day-to-day performance of their jobs. True first level manager. Ensures that project/department milestones/goals are met and adhering to approved budgets. Has full authority for personnel actions. To be a Provider Billing Investigation Manager typically requires 5 years experience in the related area as an individual contributor. 1-3 years supervisory experience may be required. Extensive knowledge of the function and department processes.
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