MetLife

Job Description: FWA, Network & Managed Care Oversight Officer

Key Responsibilities

FWA Oversight & Risk Management

·       Lead the oversight of FWA detection and prevention processes, including governance of tools, rules, and investigation frameworks

·       Drive timely escalation, investigation, and closure of suspected FWA cases, in coordination with relevant stakeholders including TPA.

·       Continuously enhance FWA controls, analytics, and reporting frameworks in conjunction with TPA governance.

TPA Governance & Performance Management

·       Act as a central governance point for TPA operations, ensuring adherence to SLAs, KPIs, and contractual requirements

·       Monitor and assess TPA claims adjudication quality, accuracy, and consistency

·       Conduct periodic governance reviews and performance assessments of TPAs

Provider Network Performance Oversight

·       Oversee provider performance and billing behavior through TPA data and insights

·       Perform network provider onsite & offsite audits 

·       Support implementation of corrective actions, cost containment strategies, and provider engagement initiatives

Stakeholder Management & Collaboration

·       Collaborate with TPAs, provider networks, internal teams (Claims, Medical, Compliance, Finance), and external stakeholders

·       Present insights, findings, and recommendations to management and cross-functional teams

·       Support training, feedback, and capability building initiatives across TPAs

Reports to: Head of Managed Care Services

Direct Reports: NA

CANDIDATE QUALIFICATIONS:

Business Knowledge/Technical Skills: 

·       3 - 5 years of experience with provider and / or payer to have a strong knowledge of billing patterns and coding 

·       Strong record of success in data analytics and identification of fraud patterns within claims.

·       Possess skills to develop creative solutions for medical quality management

·       Possess skills for feedback mechanism for different stakeholders

·       A graduate degree, MBA degree or other advance degree is preferred

·       A nursing degree or Pharmaceutical or Medical degree will be of value however not mandatory.

MetLife is proud to be an equal opportunity employer.  We are committed to attracting, retaining and maximizing the performance of a diverse and inclusive workforce.  It is the policy of MetLife to ensure equal employment opportunity without discrimination on any basis protected by law.