Manager SIU

CareSource•Dayton, OH

11d

About The Position

Job Summary: The Manager, Program Integrity is responsible for managing Program Integrity requirements to include allegation intake, report analysis, triage, investigation, correction and reporting of fraud, waste and abuse Essential Functions: Responsible for deposition, testifying in court in support of CareSource and Attorney General legal actions Manage all efforts of your investigative team focusing on thorough but timely investigations, highest impact prioritization, root cause identification, state and federal law enforcement collaboration, evidence development and investigative actions Drive and encourage innovative approaches to increase department effectiveness and efficiency Ensure quantitative and qualitative measures are used to meet performance objectives Develops and maintains key business contacts for investigative and SIU management purposes Ensure employees meet all state and federal contract requirements and follow department work processes Lead the Investigative team through investigative resolution including corrective action plans, terminations, Fair Hearings, recoveries, negotiations, mediation, and litigation Mentor employees on effective and through investigative case presentation Mentor direct reports including, coaching, development, performance feedback, disciplinary issues, annual performance evaluations and bonus review Lead and promote Employee Engagement Drive fraud identification through information sharing efforts, OIG Work Plan, Fraud Task Force participation and seminars Drive internal process and procedure changes by working with cross departmental teams to resolve identified internal system gaps that may present a FWA or financial risk to CareSource Take a leadership role in state and federal regulatory audits Proactively manage investigative team growth to meet new business requirements Take a leadership role in state and federal program integrity operations and fraud organizations such as NHCAA, HFPP, and ACFE Speak at national conferences on investigative efforts and fraud trends. Develop and maintain an in-depth knowledge of the company’s business and regulatory environments Works closely with leadership to establish, communicate, and perpetuate the corporate vision, ensuring appropriate communication to all stakeholders Recognize and proactively manage operational dependencies and risks Maintains a framework of standards and best practice methodologies that are repeatable and evidence based Participate in strategic planning and implement action plans Perform any other jobs, as requested

Requirements

Bachelor of Science/Arts Degree in Criminal Justice, Medical/Health Care Field or related industry or equivalent years of relevant work experience is required
Minimum of six to eight (6-8) years of investigative or health care experience is required
Extensive experience in health care, legal, auditing, claims and/or investigative services is required
Demonstrated leadership qualities
Support the development of effective working relationships with business partners
Solid understanding of claims processing preferred
Intermediate to advanced proficiency level of computer skills, including Microsoft Outlook, Word, Excel, Access, and Power Point
Advanced troubleshooting and problem-solving capabilities
Effective communication and interaction skills
Ability to formally present to a wide audience internally and at national conferences
Ability to lead a team and achieve performance metrics
Highest levels of ethics, integrity and professionalism
Significant knowledge of government program compliance requirements – Medicare, Medicaid, Affordable Care Act (ACA), etc. preferred
Significant knowledge of medical insurance and/or state regulatory requirements

Nice To Haves

Leadership/supervisory experience preferred
Certified Fraud Examiner (CFE), Certifications through America’s Health Insurance Plans (AHIP), Healthcare Anti-Fraud Association (HCAFA) and/or Managed Healthcare Professional (MHP), Accredited Health Care Fraud Investigator (AHFI), and/or Certified Professional Coder (CPC) are preferred

Responsibilities

Responsible for deposition, testifying in court in support of CareSource and Attorney General legal actions
Manage all efforts of your investigative team focusing on thorough but timely investigations, highest impact prioritization, root cause identification, state and federal law enforcement collaboration, evidence development and investigative actions
Drive and encourage innovative approaches to increase department effectiveness and efficiency
Ensure quantitative and qualitative measures are used to meet performance objectives
Develops and maintains key business contacts for investigative and SIU management purposes
Ensure employees meet all state and federal contract requirements and follow department work processes
Lead the Investigative team through investigative resolution including corrective action plans, terminations, Fair Hearings, recoveries, negotiations, mediation, and litigation
Mentor employees on effective and through investigative case presentation
Mentor direct reports including, coaching, development, performance feedback, disciplinary issues, annual performance evaluations and bonus review
Lead and promote Employee Engagement
Drive fraud identification through information sharing efforts, OIG Work Plan, Fraud Task Force participation and seminars
Drive internal process and procedure changes by working with cross departmental teams to resolve identified internal system gaps that may present a FWA or financial risk to CareSource
Take a leadership role in state and federal regulatory audits
Proactively manage investigative team growth to meet new business requirements
Take a leadership role in state and federal program integrity operations and fraud organizations such as NHCAA, HFPP, and ACFE
Speak at national conferences on investigative efforts and fraud trends.
Develop and maintain an in-depth knowledge of the company’s business and regulatory environments
Works closely with leadership to establish, communicate, and perpetuate the corporate vision, ensuring appropriate communication to all stakeholders
Recognize and proactively manage operational dependencies and risks
Maintains a framework of standards and best practice methodologies that are repeatable and evidence based
Participate in strategic planning and implement action plans
Perform any other jobs, as requested