Manager SIU

ManagerManagerFull TimeRemoteTeam 1,001-5,000Since 30+ yearsH1B SponsorCompany SiteLinkedIn

Location

Ohio

Posted

67 days ago

Salary

$83K - $132.8K / year

Bachelor Degree6 yrs expEnglish

Job Description

• The Manager, Program Integrity is responsible for managing Program Integrity requirements to include allegation intake, report analysis, triage, investigation, correction and reporting of fraud, waste and abuse. • Responsible for deposition, testifying in court in support of CareSource and Attorney General legal actions. • Manage all efforts of your investigative team focusing on thorough but timely investigations, highest impact prioritization, root cause identification, state and federal law enforcement collaboration, evidence development and investigative actions. • Drive and encourage innovative approaches to increase department effectiveness and efficiency. • Ensure quantitative and qualitative measures are used to meet performance objectives. • Develops and maintains key business contacts for investigative and SIU management purposes. • Ensure employees meet all state and federal contract requirements and follow department work processes. • Lead the Investigative team through investigative resolution including corrective action plans, terminations, Fair Hearings, recoveries, negotiations, mediation, and litigation. • Mentor employees on effective and through investigative case presentation. • Mentor direct reports including, coaching, development, performance feedback, disciplinary issues, annual performance evaluations and bonus review. • Lead and promote Employee Engagement. • Drive fraud identification through information sharing efforts, OIG Work Plan, Fraud Task Force participation and seminars. • Drive internal process and procedure changes by working with cross departmental teams to resolve identified internal system gaps that may present a FWA or financial risk to CareSource. • Take a leadership role in state and federal regulatory audits. • Proactively manage investigative team growth to meet new business requirements. • Take a leadership role in state and federal program integrity operations and fraud organizations such as NHCAA, HFPP, and ACFE. • Speak at national conferences on investigative efforts and fraud trends. • Develop and maintain an in-depth knowledge of the company’s business and regulatory environments. • Works closely with leadership to establish, communicate, and perpetuate the corporate vision, ensuring appropriate communication to all stakeholders. • Recognize and proactively manage operational dependencies and risks. • Maintains a framework of standards and best practice methodologies that are repeatable and evidence based. • Participate in strategic planning and implement action plans. • Perform any other jobs, as requested.

Job Requirements

  • Bachelor of Science/Arts Degree in Criminal Justice, Medical/Health Care Field or related industry or equivalent years of relevant work experience is required
  • Minimum of six to eight (6-8) years of investigative or health care experience is required
  • Extensive experience in health care, legal, auditing, claims and/or investigative services is required
  • Leadership/supervisory experience preferred
  • Solid understanding of claims processing preferred
  • Knows and uphold the provisions of the Corporate Compliance Plan
  • Intermediate to advanced proficiency level of computer skills, including Microsoft Outlook, Word, Excel, Access, and Power Point
  • Advanced troubleshooting and problem-solving capabilities
  • Significant knowledge of government program compliance requirements – Medicare, Medicaid, Affordable Care Act (ACA), etc. preferred
  • Significant knowledge of medical insurance and/or state regulatory requirements.
  • Certified Fraud Examiner (CFE), Certifications through America’s Health Insurance Plans (AHIP), Healthcare Anti-Fraud Association (HCAFA) and/or Managed Healthcare Professional (MHP), Accredited Health Care Fraud Investigator (AHFI), and/or Certified Professional Coder (CPC) are preferred.

Benefits

  • We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.

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