Manager of Healthcare Special Investigations Unit (SIU) (43913)

The Manager of Healthcare Special Investigations Unit (SIU) is responsible for developing, overseeing and managing the Special Investigations Unit (SIU) department to align with regulatory and/or contractual requirements which combines the responsibilities and activities of provider audit(s), fraud waste and abuse (FWA) and program integrity.

This position oversees the intake and tracking of all new alleged complaints/incidents of FWA, assigns cases and manages caseloads to investigative and auditing staff, assists in formulating investigative action plans, engages and partners with internal and external business partners that support FWA activities, coordinates activities with Federal and State law enforcement and regulatory agencies, manages and assists in the development and maintenance of processes and procedures necessary to effectuate the SIU functions, and sets priorities based on current SIU actions and staffing assignments.

Duties and Responsibilities

Responsibilities include, but are not limited to:

• Ensure SIU staff log and thoroughly document all provider audit and FWA complaints, incidents and leads
• Provide coordination to all SIU team members on recommendations and further actions and/or resolution to support investigative needs
• Create partnerships with other departments to create and maintain process flows for provider audit, FWA and program integrity functions
• Manage and organize meetings with providers, employees, business partners and where appropriate, representatives from regulatory agencies and law enforcement in conduct of investigations and on-site audits
• Maintain effective lines of communication with Compliance Officer, Compliance Committee, Legal Counsel and other applicable individuals as required, providing regular updates on all FWA issues with escalation, as needed
• Review and assist SIU staff in preparation of assessments and audits, case summaries and detailed reports, as needed
• Manage all SIU outbound reporting activities and ensures regulatory and other timelines are met
• Develop and maintain contacts/ liaison with law enforcement, regulatory agencies, task force members, other SIU staff, and other external contacts involved in fraud investigation, detection and prevention
• Engage in on-going performance management of staff including coaching, mentoring, development, training and succession planning to include hiring and termination decisions
• Handle people-related tasks involving new talent, employee engagement, and career development
• Other duties as assigned
• Corporate Compliance Responsibility - As an essential function, responsible for complying with Neighborhood's Corporate Compliance Program, Standards of Business Conduct, applicable contracts, laws, rules and regulations, policies and procedures as it applies to individual job duties, the department, and the Company. This position must exercise due diligence to prevent, detect and report unlawful and/or unethical conduct by fellow co-workers, professional affiliates and/or agents

Qualifications

Required:

• Bachelor's degree in business, Criminal Justice, Medical/Healthcare or related field; or a minimum o five (5) + years of relevant work experience in lieu of a degree
• Minimum of five (5) years investigative or health plan/health care operations experience
• Good working knowledge of regulatory requirements/standards
• Superior written and oral communications
• Excellent quantitative and analytic skills
• Ability to build and maintain relationships internally and externally - across business units, and with State and Federal regulatory agencies
• Ability to lead others to achieve desired results in a cross-functional environment, including (but not limited to):
• Ability to assess individual performance and communicate assessments effectively
• Ability to identify and effectively and efficiently resolve employee performance issues
• Ability to establish goals and assist others to achieve goals and meet expectations
• Ability to lead others to improve work processes

• Previous experience conducting compliance monitoring and audit reviews
• Demonstrated ability to effectively prioritize and execute tasks in a high-pressure environment and meet contractual timelines
• Proficient with learning & using various technology software tools, including Microsoft Office

Preferred:

• Direct/indirect supervisory experience

Salary Grade: J