Mgr, SIU

Location: Tampa

Reports To: Sr. SIU Director

Department: Compliance - SIU & Corp. Investigation

Supervises team of investigators in the Special Investigation Unit (SIU), to detect, investigate, remediate and refer to law enforcement as appropriate incidents of fraud, waste and abuse (FWA), arising in connection with medical, behavioral, dental and other healthcare services. Duties include managing case assignments, case development, case review, overpayment recoveries, law enforcement referrals, training of staff, and coordination with other departments to mitigate and remedy FWA.

Essential Functions:

  • Accountable for the performance of assigned SIU investigators.
  • Manages day-to-day activities of assigned SIU investigators by: assigning cases to staff based on skills and resources to ensure proper prioritization of cases; fostering a collegial and positive work environment; managing, mentoring, and directing individual and team performance; monitoring progress with individual and team performance goals
  • Develops and implements plan for prospective and retrospective fraud, waste and abuse (FWA) avoidance, detection, investigation, and recovery.
  • Implements plan to remediate FWA and to maximize recoveries related to FWA, with a demonstrated ability to achieve results.
  • Monitors compliance with company policies and procedures and compliance with pertinent FWA provisions of state contracts.
  • Coordinates SIU activities with other departments, providers, members, vendors, regulatory and law enforcement agencies.
  • Assists in development and presentation of FWA training processes.
  • Coordinates litigation support for SIU matters referred to Legal Department.
  • Performs other duties as assigned.
Additional Responsibilities:
    Candidate Education:
    • Required A Bachelor's Degree in a related field or Business, Finance, Accounting, Criminal Justice
    Candidate Experience:
    • Required 10 years of experience in professional investigative experience in law enforcement, health care, insurance, or a related area.
    • Required 3 years of management experience that clearly demonstrates leadership
    • Required Other Experience in developing and implementing anti-fraud plans, policies and procedures, training materials, work flow diagrams, standard operating procedures or other documentation as required
    • Preferred Other Experience and familiarity with data analysis and data mining for purposes of fraud detection
    • Preferred Other Demonstrated experience in successful overpayment recovery
    Candidate Skills:
    • Intermediate Ability to work within tight timeframes and meet strict deadlines
    • Intermediate Ability to identify basic problems and procedural irregularities, collect data, establish facts, and draw valid conclusions
    • Intermediate Ability to lead/manage others
    • Intermediate Ability to work in a fast paced environment with changing priorities
    • Advanced Other Extremely high ethical standards are required
    • Ability to analyze and interpret financial data in order to coordinate the preparation of financial records
    • Intermediate Other Excellent leadership, team building and strategic thinking skills.
    • Advanced Other Excellent verbal and written communication skills
    • Intermediate Other Self starter, highly motivated. Ability to remain calm under pressure
    • Intermediate Knowledge of medical terminology and/or experience with CPT and ICD-9 coding Maintain current knowledge of suspected FWA trends and matters of interest to law enforcement and regulators
    Licenses and Certifications:
    • Preferred Other Credentials such as Certified Fraud Examiner, Accredited Healthcare Fraud Investigator, Certified Insurance Fraud Investigator, Certified Public Accountant, Certified Internal Auditor, Certified Compliance Professional, or other similar licensure/certification
    Technical Skills:
    • Required Intermediate Microsoft Excel Proficiency in MS-Office applications (MS-Word, MS-Excel, MS-Access, MS-Powerpoint, and MS-Outlook) required
    • Required Intermediate Microsoft Access
    • Required Intermediate Microsoft Word Technical knowledge, skills and abilities sufficient to become proficient in company applications
    • Required Intermediate Microsoft Outlook Working knowledge of common medical terminology, ICD-9, CPT, HCPCS and UB Revenue codes
    • Required Intermediate Microsoft PowerPoint

      About us
      Headquartered in Tampa, Fla., WellCare Health Plans, Inc. (NYSE: WCG) focuses exclusively on providing government-sponsored managed care services through Medicaid, Medicare Advantage and Medicare Prescription Drug Plans to families, children, seniors and individuals with complex medical needs. WellCare is a Fortune 500 company, and in 2018, was recognized as a Fortune "World's Most Admired Company", ranking in the top five among the health insurance and managed care industry-a testament to the hard work and dedication of the company's nearly 9,000 associates who each day live WellCare's values and deliver on its mission to help its members live better, healthier lives. The company serves approximately 4.4 million members nationwide as of Dec. 31, 2017. For more information about WellCare, please visit the company's website at EOE: All qualified applicants shall receive consideration for employment without regard to race, color, religion, creed, age, sex, pregnancy, veteran status, marital status, sexual orientation, gender identity or expression, national origin, ancestry, disability, genetic information, childbirth or related medical condition or other legally protected basis protected by applicable federal or state law except where a bona fide occupational qualification applies. Comprehensive Health Management, Inc. is an equal opportunity employer, M/F/D/V/SO.