Manager Special Investigations

Health Care Service Corporation•Chicago, IL

5d•$92,700 - $167,500•Hybrid

About The Position

HCSC is looking for a dynamic individual to join its Fraud Investigations team! This position will be responsible for managing healthcare fraud and internal fraud investigations initially focusing on IL Medicaid; managing and training investigators as well as support staff; establishing and maintaining liaison with healthcare providers and law enforcement; and coordinating anti-fraud activities with other departments at HCSC. The role is hybrid flex and requires in-office visibility three days per week, working from home the other two days. NOTE: relocation is NOT offered, sponsorship will NOT be extended either now or in the future.

Requirements

Bachelor’s Degree in Criminal Justice, Finance or Accounting or related field and 5 years of direct law enforcement/investigation experience, including supervision of cases and investigators OR 9 years of direct professional work experience in the detection, investigation and/or prosecution of complex health care fraud schemes with the following professional certifications: Accredited Healthcare Fraud Investigator (AHFI), Certified Professional Coder (CPC), and/or Certified Fraud Examiner (CFE).
1 year of leadership or supervisory experience.
Strong organizational skills and results oriented with demonstrated leadership capabilities.
Keen analytical, interviewing, and investigative skills, with proficiency in data analysis and claims management systems.
Deep understanding of insurance fraud techniques, claims handling, and regulatory compliance.
Proficiency in anti-fraud analytics tools, case management software, and MS Office (Word, Excel, PowerPoint) as well as Workday.

Nice To Haves

Master’s Degree.
Experience with IL Medicaid FWA investigations.

Responsibilities

Develop and manage investigative group designed to detect, investigate, and refer health care fraud cases to law enforcement.
Ensure evidence collected, including documents and interview reports, are maintained in a manner to ensure integrity in court proceedings.
Ensure personnel are properly trained and managed in investigative techniques.
Prepare weekly investigative and activity reports.
Coordinate with other HCSC departments concerning ongoing anti-fraud programs and procedures.
Develop and maintain sources of information needed to detect health care fraud.
Develop and maintain liaison contacts with law enforcement.
Direct and supervise sensitive investigations when appropriate.
Deal directly with HCSC customers on fraud matters when appropriate.
Conduct monthly file reviews and provide direction to investigators regarding investigative strategies and plans.
Coordinate investigative activities with the Legal Department.
Ensure investigators are familiar and utilize health care fraud databases, including Fraud and Abuse Management System (FAMS).
Comply with federal and state reporting and fraud investigation requirements.
Communicate and interact effectively and professionally with co-workers, management, customers, etc.
Comply with HIPAA, Diversity Principles, Corporate Integrity, Compliance Program policies and other applicable corporate and departmental policies.
Maintain complete confidentiality of company business.
Maintain communication with management regarding development within areas of assigned responsibilities and perform special projects as required or requested.