Director, Special Investigations Unit - AHFI

SCAN Health Insurance•Long Beach, CA

2d•$147,000 - $190,000•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. This role involves leading and developing the SIU Infrastructure, overseeing and being responsible for the activities of SIU for accurate and timely investigative cases. The Director will manage and be responsible for resolving complex investigative cases and/or issues to ensure accurate, cost effective, and compliant operations. Additionally, this role includes conducting FWA training/education with staff and departments across the organization, developing FWA and protocols for the health delivery model for portfolio companies, and managing the overall supervision, planning, organization, and execution of SCAN's fraud, waste, and abuse program. The Director will work closely with the VP of Internal Audit regarding strategy, lead and support the activities of the SIU team, interpret audit results, and assist health plan executives in developing appropriate action plans. This position also involves monitoring, overseeing, and evaluating vendors, identifying and directing the implementation of qualified personnel, processes, and technologies, and ensuring compliance with all state and federal regulations for fraud, waste, and abuse. Collaboration with Legal on legal inquiries, attendance at federal and state fraud meetings, and preparation of materials for the SCAN Group Board Compliance Committee are also key responsibilities. The role includes developing fraud risk assessments and coordinating participation in FWA/SIU industry associations. Building and maintaining relationships with regulators and investigatory units, fostering a culture of compliance, and providing guidance to management at portfolio companies on FWA matters are essential. The company is seeking individuals who are curious about AI and its potential to transform operations and member service, and who will actively support SCAN’s Vision and Goals. Other duties as assigned.

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
Risk Adjustment and Coding experience/expertise preferred.
3+ years of experience within healthcare industry, 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

Nice To Haves

Risk Adjustment and Coding experience/expertise
3+ years of experience within healthcare industry
Certified Criminal Justice Specialist (CCJS)
Accredited Health Care Fraud Investigator (AHFI)
Certified Fraud Examiner (CFE)
Certified Healthcare Compliance (CHC)

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

Base Pay Range: $147,000-$190,000
Salary
An annual employee bonus program
Robust Wellness Program
Generous paid-time-off (PTO)
11 paid holidays per year
1 floating holiday
birthday off
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!
A competitive compensation and benefits program
Eleven paid holidays per year
Excellent Retirement Savings program
A work-life balance