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Role Description

Position acts as a subject matter expert in the field of Compliance and/or Special Investigations Unit (SIU) investigations. Provides direction and guidance to staff who investigate and remediate compliance and fraud, waste, and abuse related matters; while maintaining an investigative workload of moderate to high complexity. Assists manager on monitoring team caseload and report on metrics.

• Provides guidance to team members who investigate and remediate compliance and fraud, waste, and abuse related matters.
• Assists manager on monitoring team caseload and report on metrics.
• Identifies training needs and develops training aids and step actions.
• Provides training and mentoring to team on casework and other SIU activities.
• Evaluates and assesses allegations to determine those criteria, including federal and state regulations, Centers for Medicare & Medicaid Services (“CMS”) guidelines, and internal policies, procedures, and standards that are alleged to have been violated.
• Conducts and documents interviews for investigatory purposes.
• Reviews investigative interviews prepared by junior investigators.
• Manages caseloads of moderate to high complexity, develops investigative plans for multiple investigations, prioritizing and managing through execution.
• Thoroughly documents actions, organizes, and reviews case files.
• Consults with management, in-house counsel, and/or senior leadership to resolve difficult or complex issues.
• Identifies risks and recommends and communicates remedial actions to mitigate future potential risks.
• Performs follow-up to ensure remedial and disciplinary measures are implemented appropriately and timely.
• Prepares clear and concise investigative plans and reports.
• Provides support and guidance to junior investigative staff.
• Identifies trends and aberrant activity to generate proactive leads for investigations and analyzes data to detect potentially fraudulent activity.
• Attends, actively participates in, and/or leads meetings with various business area managers.
• Communicates directly with Federal or State regulators.
• Prepares cases for referral to management, government agencies, and law enforcement.
• Develops and maintains strong working relationships with associates and regulators.
• Testifies in criminal and civil matters.
• Supports the development and maintenance of Corporate Compliance policies and procedures and workflows.
• Participates in and leads special projects as needed.
• Performs other duties as assigned.
• Complies with all policies and standards.

Qualifications

• Bachelor's Degree in related field; or Associate's degree with 6 years related experience; or High School Diploma/GED with 7 years related experience required.
• Master's Degree preferred.
• 5+ years Healthcare fraud-related investigations with audit and risk analysis required.
• 1+ years Managed care or working with health insurance company required.
• In-depth knowledge of government programs, the managed care industry, Medicare, Medicaid laws and requirements, federal, state, civil and criminal statutes required.
• Reading, analyzing and interpreting State and Federal laws, rules and regulations. Knowledge of community, state and federal laws and resources required.
• Knowledge and understanding of managed care claims processing systems and medical claims coding preferred.

Licenses/Certifications

• Accredited Health Care Fraud Investigator (AHFI), Certified Fraud Examiner (CFE), Certified Pharmacy Technician, or other industry related certification preferred.

Benefits

• Competitive pay.
• Health insurance.
• 401K and stock purchase plans.
• Tuition reimbursement.
• Paid time off plus holidays.
• Flexible approach to work with remote, hybrid, field or office work schedules.