Director, Special Investigations Unit should have experience directing investigations, mentoring, reporting outcomes/recommendations for reduction to fraud, waste, and abuse, and have excellent prioritization and organizational skills. Required skills include developing processes to mitigate/report fraud, waste and abuse and conduct data analysis/risk assessments. Candidate should be familiar with Medicaid/Medicare regulations, possess strong oral and written communication skills and be able to collaborate effectively with internal and external departments, as necessary. Familiarity with Medicaid regulations specifically targeted case management and psychosocial rehab services preferred. Knowledge of CPT codes, HIPAA, Excel and Word required.
Oversee fraud investigations unit for the purpose of detecting, investigating and deterring fraud, waste, and abuse including overpayments to ensure compliance with state and federal regulatory and contractual requirements.
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Serves as subject matter expert for fraud, waste and abuse schemes and mitigation activities.
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Investigates allegations of suspected fraud, waste and abuse.
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Directs investigations, coordinate settlements and recoveries, and supervise SIU investigators.
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Interacts with internal and external customers including executive management, providers, members, law enforcement, state agencies and other stakeholders.
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Develops and implements processes and procedures to detect, investigate, mitigate and report fraud, waste and abuse.
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Ensures compliance with federal and state regulatory compliance and fraud, waste and abuse investigation and reporting requirements.
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Responds to RFPs, RFIs, and audits.
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Conducts risk assessments annually including identifying and assessing risks related to fraud, waste and abuse. Conduct and coordinate activities to evaluate and mitigate identified risks.
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Develops and conducts educational activities related to fraud, waste and abuse and related topics.
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Conducts data analysis to identify patterns and trends related to fraud, waste and abuse.
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Ensures complete documentation related to all fraud, waste and abuse activities.
Qualifications:
- Bachelor’s degree in a related field or equivalent combination of education and experience is required
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10 of experience working in a SIU, insurance investigations, or a related field is required.
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Experience leading and developing direct reports required
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Proven experience in criminal/civil insurance investigation and have a working knowledge of provider contracts, member certificates of coverage, claims processing procedures and/or payment integrity required
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Prior work experience collaborating with FBI, HHS-OIG, Assistant U.S. Attorneys, MFCUs or State Attorney Generals preferred
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Experience in anti-fraud investigations in a data-driven environment
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Knowledge of anti-fraud investigative tools, techniques, analytics and reporting
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Program management, leadership, team building, resource planning, and supervisory experience
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Established working relationship with law enforcement and/or government agencies is preferred
License and Certifications - Preferred
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Accredited Healthcare Fraud Investigator – Enterprise (AHFI)
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Certified Fraud Examiner – Enterprise (CFE)
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Fraud Claims Law Specialist (FCLS)
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Health Care Anti-Fraud Associate (HCAFA)
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Certified Insurance Fraud Investigator (CIFI)
Skills and Abilities:
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Significant impact on function and business objectives by application of professional principles. Significant contribution to team processes to meet objectives.
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Work collaboratively with other Medica departments to develop improvements in abuse and fraud detection and to create and implement system-wide enhancements to achieve financial savings and minimize financial liability for the
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Curious, detail-oriented and inquisitive mindset.
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Organizational and time management skills, along with an ability to skillfully handle time-sensitive projects.
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Analytical, problem-solving and decision-making skills to work through challenging and complex case details.
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High degree of integrity and confidentiality required for handing information that is personal and confidential.
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Strong written and verbal communication skills, including the ability to obtain information from others and deliver information in a concise, clear, and accurate manner.
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The ability to navigate and understand claims data and various databases to identify and document suspected FWA.
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Ability to work collaboratively, build coalitions and resolve conflicts, including success in managing cross-functional initiatives.
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Interpersonal skills, with the ability to listen, coach, and provide technical direction to others and to interact with tact and professionalism with all levels of the organization and external contains.
This position requires COVID-19 vaccination per Medica’s Employee COVID-19 Vaccination Policy. If you are hired, you would be expected to be fully vaccinated for COVID-19 prior to starting the position, unless a medical or religious exemption is needed. Medica is an Equal Opportunity Employer and provides reasonable accommodations in compliance with the ADA and Title VII.
Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities
The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor’s legal duty to furnish information. 41 CFR 60-1.35(c)