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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.
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
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
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
Licenses and Certifications: A license in one of the following is required:
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