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Role Description

The Director, Special Investigations Unit (SIU), reports to the General Counsel and Chief Legal Officer and leads the Martin’s Point’s Audit & Recovery team. Responsible for developing and implementing a fraud, waste, and abuse program encompassing a wide range of investigations, audits, and medical code editing scenarios, including but not limited to appropriate oversight of Martin’s Point’s risk adjustment activities. Ensures all audits and investigations are performed and documented in compliance with applicable federal and state fraud, waste, and abuse (FWA) guidelines.

• Accountable for the overall supervision, planning, organization, and execution of MPHC’s fraud, waste, and abuse program.
• Leads, manages and supports the activities of the Audit & Recovery team to ensure accurate and timely audits and investigations.
• Conducts risk adjustment oversight activities and participates in risk adjustment governance structure.
• Interprets audit results and assists health plan executives in the development of appropriate action plans to address identified issues, including but not limited to financial recovery efforts.
• Monitors, oversees, and evaluates vendors performing audit and recovery activities.
• Identifies and directs the implementation of qualified personnel with appropriate expertise, improved processes, and new technologies.
• Ensures compliance with all state and federal regulations for fraud, waste, and abuse, including but not limited to reporting obligations.
• In collaboration with Legal, responds to all legal inquiries including subpoenas and court appearances.
• Attends federal (CMS and/or DHA) and state fraud meetings and industry events and training.
• Prepares reporting for business teams, Executive Management Team, and the Board of Directors.
• Coordinates MPHC’s participation in FWA/SIU industry associations, coalitions, and stakeholder groups, leveraging participation in those organizations to support MPHP’s program.
• Builds and maintains strong relationships with federal and state regulators, investigatory units, and enforcement agencies.
• Helps lead a culture of compliance with applicable laws and regulations, corporate citizenship, and diversity, equity, inclusion, and belonging.

Qualifications

• Bachelor's degree in Accounting, Criminal Justice, Finance, Medical Professional, Economics, Operations Management, or related field or equivalent.
• Juris Doctor or other applicable advanced degree preferred.
• 10+ years of related compliance, FWA, and/or special investigation experience in managed care or CMS.
• Risk Adjustment experience/expertise preferred.
• Track record of progressive leadership responsibilities and achievements, as well as significant team management experience.
• Significant experience partnering with cross-functional teams.

Requirements

• CFE, PCI, or CCJS certification preferred.

Skills/Knowledge/Competencies

• Proven capacity to operate in matrixed organizations across all levels of leadership and in support of different business areas.
• Command of current health care FWA issues at the federal and state level and deep knowledge of regulatory requirements and processes.
• Knowledge and integrity consistent with the company's values and ability to be a trusted partner to leadership and internal stakeholders.
• Executive presence that engenders confidence from federal and state regulators and investigative agencies.
• Excellent judgment, poise, and strong negotiation skills.
• Highly advanced communication skills and comfortable making cogent, high impact presentations to audience of all sizes and types that motivate action; ability to effectively write for impact.
• Proactive problem-solving, a track record of persuasive advocacy, and strong organizational and time management skills.
• Demonstrated ability to handle matters of a sensitive and confidential nature and the capacity to maintain composure while working under pressure.

Equal Opportunity Statement

This position is not eligible for immigration sponsorship. We are an equal opportunity/affirmative action employer. Martin's Point complies with federal and state disability laws and makes reasonable accommodations for applicants and employees with disabilities. If a reasonable accommodation is needed to participate in the job application or interview process, to perform essential job functions, and/or to receive other benefits and privileges of employment, please contact jobinquiries@martinspoint.org.

Do you have a question about careers at Martin’s Point Health Care? Contact us at: jobinquiries@martinspoint.org.