Investigations Manager
About The Position
The Investigations Manager provides critical support within the Program Integrity Unit and the Office of Inspector General, helping safeguard the Department of Community Health from fraud, waste, and abuse. The role manages two direct reports who investigate providers for fraud, waste, and abuse in the Fee-for-Service Medicaid program. The manager guides and provides feedback to the team to support adherence to performance metrics and timely business processes. The position analyzes claims data to identify aberrant provider billing trends and facilitate utilization review. It leads provider on-site visits throughout Georgia to request medical records, conduct interviews, and tour facilities to verify that appropriate medical equipment is available to support services billed to Medicaid. The manager also reviews documentation related to Participant and Consumer Directed Care services, referrals, and hotline complaints, and participates in Surveillance Utilization Review meetings to identify providers for utilization review.
Requirements
- Bachelor's degree in operations management, business administration, or a related field, with three years of experience in a managerial or supervisory role; or seven years of related professional experience, including three years in a managerial or supervisory role; or three years of experience at the lower-level Manager, Business Operations (GSM010) or an equivalent position.
- An equivalent combination of knowledge, education, job or internship experience, training, or certifications may be substituted year-over-year if it provides the knowledge and skills necessary to perform the job.
Responsibilities
- Manage two direct reports investigating providers for fraud, waste, and abuse in the Fee-for-Service Medicaid program.
- Provide team guidance and feedback to support performance metrics and timely business processes.
- Analyze claims data to identify aberrant provider billing trends and facilitate utilization review.
- Conduct and lead provider on-site visits throughout Georgia to request medical records, conduct interviews, and tour facilities to verify appropriate equipment is available for services billed to Medicaid.
- Review documentation for Participant and Consumer Directed Care services to investigate allegations of false claims billed to Medicaid.
- Review referrals and hotline complaints and participate in Surveillance Utilization Review meetings to identify providers for utilization review.
Benefits
- Robust benefits package
Stand Out From the Crowd
Upload your resume and get instant feedback on how well it matches this job.
What This Job Offers
Job Type
Full-time
Career Level
Manager
