SIU Department Manager

The SIU Manager is responsible for the day-to-day operation of the Special Investigations Unit, managing investigators and analysts, in addition to carrying an investigative caseload, ensuring all investigations are conducted appropriately and ethically. The SIU team is responsible for detecting and investigating suspected fraud, waste, and abuse (FWA) across multiple lines of business.

Required:

• Education: Bachelor's Degree;
• Experience: At least 18 months investigating healthcare fraud;
• Demonstrated understanding of healthcare FWA and PI processes and procedures;
• Certified Coder (or eligible within 6 months);
• Knowledge of ICD-9/10, CPT, HCPCS, DRG, and/or Rev codes;
• Advanced proficiency with Office products, including Word and Excel;
• Excellent written and oral communication skills;
• Critical problem-solving skills and attention to detail.

Desired:

• Experience in a federally regulated environment, such as Medicaid or Medicare;
• Management experience.

Responsibilities:

• Oversees the day-to-day investigative operations;
• Responsible for performance reviews and employee development;
• Utilizes knowledge of healthcare coding, medical policies, and other relevant guidelines to assess and evaluate cases;
• Reviews healthcare claims, medical records, physician statements, care management reports, provider contracts and other documentation which requires interpretation and understanding of state and federal regulations, standards of care, applicable benefit language, and reimbursement language to determine billing appropriateness and sufficiency of documentation in the evaluation of cases for potential fraud, waste, or abuse;
• Maintains own investigative caseload (i.e., a "working" manager);
• Prioritizes cases;
• Reviews and approves plans of investigation;
• Ensures case deadlines are met;
• Creates provider audit plans and oversees provider audits;
• Initiates and tracks case management improvements;
• Initiates report development and execution;
• Creates and provides training, including onboarding new employees;
• Provides first-level review and approval of referrals to outside entities;
• Reviews and approves routine external communication;
• Provides input on the annual anti-FWA plan;
• Coordinates with internal partners including Operations, Compliance, QI, Credentialing, and Provider Delivery Services to gather information relevant to the SIU;
• Speaks and acts confidently when conveying information, including explaining overpayment determinations which may include court testimony;
• Maintains certification, completing required continuing education.