Manager, SIU Provider Investigations

Point32Health • Canton, MA

5d • Hybrid

About The Position

Point32Health is currently seeking highly motivated individuals to join our organization as a Manager within our Special Investigations Unit (“SIU”). The Manager is an essential team member of the SIU, responsible for supervising, and setting investigative strategies and priorities for a team of investigators focused on provider investigations.

Requirements

• Bachelor’s degree or equivalent experience
• 5-7 years related experience in health insurance fraud investigations with at least two years in a senior investigative capacity.
• 3+ years related experience in audits/investigations.
• Computer literacy is mandatory
• Excellent writing and analytical skills.
• Excellent investigative skills
• Excellent communication skills; must be able to communicate effectively with all levels of the organization and external customers.
• Excellent organizational skills.
• Familiarity with claims data querying systems.
• Total accuracy and attention to detail.
• Sound judgment and decision-making skills.
• Ability to successfully manage in a complex environment.
• Ability to manage and be directly responsible for multiple projects running simultaneously.
• Coaching, mentoring and management skills.
• Relationship building skills required.
• Must be able to work cooperatively in a team environment.
• Sense of humor.

Nice To Haves

• Clinical License, Certified Fraud Examiner (“CFE”) or Certified Professional Coder (“CPC”) designation a plus
• Degree in a clinical or scientific field, business, computer science, or criminal justice.

Responsibilities

• Manages, develops, and motivates a team of provider investigators to ensure that all investigative leads are thoroughly and thoughtfully investigated
• Retains own caseload of high complexity investigation
• Works closely with the Director, SIU to develop, implement, and revise Point32Health’s investigative strategies, processes, and priorities, and effectively deploy investigators to meet those priorities
• Works with investigators to recommend appropriate disposition for investigations, including closure or corrective actions such as provider education, prepayment denial of claims, recovery of overpaid funds, and referrals to appropriate regulatory and law enforcement agencies
• Collaborates with the SIU’s Triage and Analytics teams to receive and prioritize referrals for investigation
• Represents the SIU on various internal working groups and committees, as needed
• Consults with various business unit leaders throughout Point32Health in order to obtain necessary evidence, cooperation, or clarification
• Develops a system involving key performance indicators to identify top performing staff
• Other projects and duties as assigned

Benefits

• Medical, dental and vision coverage
• Retirement plans
• Paid time off
• Employer-paid life and disability insurance with additional buy-up coverage options
• Tuition program
• Well-being benefits
• Full suite of benefits to support career development, individual & family health, and financial health

What This Job Offers

• Job Type: Full-time
• Career Level: Manager