Manager, Special Investigations Unit - The Health Plan

We are looking for a Manager of the Special Investigative Unit. In this role you will be responsible for the oversight of the Special Investigations Unit (SIU) and Fraud, Waste & Abuse (FWA) Program in compliance with contractual and regulatory requirements. Oversees case management, case investigation, overpayment recoveries, reporting of investigations to regulatory agencies; responds to government requests for information related to FWA; facilitates compliance with state and federal FWA requirements; develops and maintains employee education; and identifies new recovery opportunities, goals and sound practices.

Job Duties and Responsibilities

•  Coordinates with subcontractors on overseeing investigations of Fraud, Waste & Abuse (FWA).
•  Manages a large fraud investigation caseload and investigates allegations relating to potential health care fraud perpetrated by Medicaid and commercial providers, vendors and enrollees.
•  Provides internal and external case updates on progression of investigations in coordination with SIU team members and other departments, including recommendations on further action and/or resolution, as needed.
•  Continually interfaces with members, vendors, pharmacies, providers and other third parties via telephone, e-mail, and on-site visits as needed to identify, further, and conclude ongoing investigations.
•  Implements processes and procedures to: prevent, detect, investigate and report FWA to appropriate regulatory agencies.
•  Provides inter-departmental input regarding controls for preventing and monitoring FWA issues.
•  Proactively identifies trends and aberrant activity to generate leads for FWA investigations.
•  Performs special assignments related to FWA as assigned by the Director of Controls and Compliance.
•  Accountable for managing the day-to-day activities of the SIU Department, reporting directly to the Director of Controls and Compliance.
•  Develops and maintains outcome-focused SIU Policies & Procedures which are consistent with all applicable contractual and regulatory requirements.
•  Supports internal and external SIU reviews as appropriate, including accurate tracking of case information and timely reporting as needed for internal and external audits, contractual requirements, and regulatory oversight.
•  Conducts comprehensive analysis of claim utilization data to prevent payment of fraudulent claims.
•  Assist with data mining activities using available tools and applications.
•  Develops and implements plans for operations in cases of prospective and retrospective fraud, waste and abuse and overpayment recovery.
•  Provides periodic internal and external training to all staff and contractors on fraud, waste, and abuse.
•  Develops and maintains strong working relationships with company management, associates and State regulators.

Skills and Requirements

•    Required High School Diploma/GED or 
•    Bachelor’s Degree preferred
•    One of the following Certifications:
•    EDUHRUSE, 
•    CPA: Certified Public Accountant 
•    CFA: Certified Fraud Examiner
•    AHFI: NHCCA National Health Care Anti-Fraud Association
•    INT-POPC: Intermediate Peace Officer Proficiency Certificate
•    Required 8 years' experience in fraud, waste & abuse (FWA) investigations or special investigations unit (SIU), including 1 year of experience working with Medicaid

Please note: Previous experience with Fraud, Waste & Abuse within a healthcare related setting is required.  This is not a law enforcement, security officer, national security related position

Additional Note: This is a hybrid role, not a fully remote opportunity
 

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