Director, Special Investigations Unit - AHFI

GRP SCAN Group • Long Beach, CA

1d • Remote

About The Position

The Director, Special Investigations Unit position reports directly to the Vice President of Internal Audit Services and will have primary responsibility in the development of overall SIU strategies/infrastructure, assists the Vice President to lead and oversee the Special Investigations Unit function and SIU activities.

Requirements

• Bachelor’s Degree or equivalent experience
• 10+ years related compliance, FWA, and/or special investigation experience in managed-care or CMS.
• Prior experience working with regulatory agencies such as CMS, HHS, and OIG
• 3+ years of experience within healthcare industry, preferred.

Nice To Haves

• Risk Adjustment and Coding experience/expertise preferred.
• Certified Criminal Justice Specialist (CCJS), preferred
• Accredited Health Care Fraud Investigator (AHFI), Strongly preferred
• Certified Fraud Examiner (CFE), preferred
• Certified Healthcare Compliance (CHC), preferred

Responsibilities

• Lead and develop the SIU Infrastructure.
• Oversee and responsible for the activities of SIU for accurate and timely investigative cases.
• Manages and responsible for resolving complex investigative cases and/or issues to ensure accurate, cost effective, and compliant operations.
• Conduct FWA training/education with staff and departments across the organization which includes all portfolio companies (Welcome Health, Healthcare In Action, Homebase, myPlace Health).
• Develop FWA and protocols for the health delivery model for the portfolio companies.
• Manages the overall supervision, planning, organization, and execution of SCAN's fraud, waste, and abuse program.
• Works closely with the VP of Internal Audit regarding strategy.
• Leads and supports the activities of the SIU team to ensure accurate and timely audits and investigations.
• 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 and state fraud meetings and industry events and training.
• Works closely with VP of Internal Audit with SCAN Group Board Compliance Committee materials related to FWA.
• Develop fraud risk assessment.
• Coordinates participation in FWA/SIU industry associations, coalitions, and stakeholder groups, leveraging participation in those organizations to support the FWA 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.
• Provides on-going guidance to senior and mid-level management at the portfolio companies with matters related to FWA.
• Actively support the achievement of SCAN’s Vision and Goals.
• Other duties as assigned.

Benefits

• An annual employee bonus program
• Robust Wellness Program
• Generous paid-time-off (PTO)
• 11 paid holidays per year, 1 floating holiday, birthday off, and 2 volunteer days
• Excellent 401(k) Retirement Saving Plan with employer match
• Robust employee recognition program
• Tuition reimbursement
• An opportunity to become part of a team that makes a difference to our members and our community every day!

What This Job Offers

• Job Type: Full-time
• Career Level: Director
• Education Level: Associate degree