Director, Special Investigations Unit

Mass General Brigham•Somerville, MA

4d•$124,342 - $225,000•Hybrid

About The Position

The Director, Special Investigations Unit (SIU) will report to Sr. Vice President, Legal, Regulatory Affairs and Compliance and is responsible for supporting the prevention, detection, investigation, reporting, and when appropriate, recovery of money related to health care fraud, waste, and abuse. The SIU team will perform accurate and reliable medical review audits, analyze medical billing and codes, conduct confidential investigations related to compliance and regulatory requirements, documenting the investigation through audit reports for interview and external review which document the findings, and reporting issues of non-compliance in accordance with all laws and regulations. In addition, this position will review claims, look for patterns of potential fraud, waste and/or abuse and interact with medical providers to request medical records for investigations. The Director, Special Investigations Unit (SIU) is responsible for management and oversight of the Special Investigations Unit. The Director, SIU trains staff, assigns work, and resolves complex issues to ensure accurate, cost effective and compliant operations. This position is responsible for reviewing and approving work product for all levels of investigators, both clinical and non-clinical. The Director, SIU will also determine outcomes of SIU referrals during triage, as well as provide guidance to all investigators related to their investigative case plans. This position also monitors staff and departmental productivity and efficiency, while adjusting workflows/staff assignments as needed. Additionally, the Director, SIU supports the day-to-day operations and focused initiatives. This individual may function as the liaison between clinical suppliers and the SIU as it relates to the Special Investigations Unit. Responsible for overseeing insurance audits and investigations to ensure compliance with regulatory standards and protect the organization from financial risk. Manages audit processes, identifies potential fraud, and drives improvement in claims processing and reimbursement practices. Leads a team dedicated to investigating discrepancies and ensuring the integrity of insurance billing and reporting.

Requirements

Bachelor's Degree required
Health care coding certification (CPS or CCS) required
Accredited Healthcare Fraud Investigator (AHFI) certification or Certified Fraud Examiner (CFE) required.
At least 5-7 years of experience in insurance audits, investigations, or a related field required
At least 3-5 years of experience in a management role, preferably within healthcare required
Strong knowledge of insurance claims processing, billing practices, and healthcare regulatory compliance.
Analytical skills for interpreting audit results and identifying patterns of concern.
Excellent communication skills for preparing audit reports and conveying findings to leadership.
Project management skills to effectively oversee multiple audits and investigations concurrently.

Nice To Haves

Master's Degree preferred
At least 5-6 years of experience in the Managed Care industry, Medicaid or Medicaid Managed care fraud detection unit preferred.
At least 6 years of experience in a health care payer setting and/or in a health care fraud control setting highly preferred

Responsibilities

Provides oversight and review of the SIU referral intake and investigation process while giving guidance and direction to team on case investigation steps and actions.
Works with leadership to maintain and revise policies and procedures, fraud, waste, and abuse plans, annual audit work plans, including department guidance memos, and educational materials.
Identifies opportunities for improvement through the audit process and provides recommendations for system enhancement to augment investigative outcomes and performance.
Accurately tracks, reports, and follows up on overpayments and recoveries.
Leads the business requirement process and reporting to ensure proper and timely notification of case activity to the appropriate regulatory and/or law enforcement agency.
Provides direct accountability for SIU case inventory management.
Monitors and evaluates the quality, timeliness, and accuracy of team processes.
Ensures that all SIU recoveries are processed accurately and in a timely manner in compliance with the MCO contracts.
Coordinates with SIU team and gathers documentation related to requests from federal, state, and local law enforcement agencies in the investigation and prosecution of healthcare fraud and abuse matters.
Ensures that investigations progress with minimal delays, as well as provides guidance to meet State expectations as well as possible State incentives based on timeliness of investigations and referrals.
Maintains current, in-depth knowledge of all Mass General Brigham Health Plan benefits, payment policies, provider network, configuration issues, Medicaid, and Medicare billing practices.
Responsible for maintaining accurate and consistent updated SIU policies, processes and procedures and related training manuals.
Responsible for staff hiring, work allocation and scheduling, training and professional development, performance management and related supervisory activities.
Responsible for leading triage meetings, as well as determining outcomes of each lead.
Review all requests to open investigations, fraud referrals, corrective action plans and provider letters to ensure quality, accuracy, and clarity before submission to States for approval.
Provide guidance to all investigators related to investigative case plans.
Managing SIU work queues, as well as ensuring SIU appeals are resolved timely.
Collaborates with other department supervisors in the planning, development, and coordination of department specific and cross-functional initiatives.
Facilitates team meetings as well as clinical supplier meetings and may lead and represent the SIU in various state FWA related regulatory meetings.
Identifies, communicates, and escalates issues on a timely basis.
Independently problem solves programmatic issues and implements appropriate solutions.
Develops and oversees the production of standard KPI reports to monitor and report on overall department metrics and inventory management.
Hold self and others accountable to meet commitments.
Ensure diversity, equity, and inclusion are integrated as a guiding principle.
Persist in accomplishing objectives to consistently achieve results despite any obstacles and setbacks that arise.
Build strong relationships and infrastructures that designate Mass General Brigham Health Plan as a people-first organization.
Other duties as assigned with or without accommodation