Manager, Special Investigative Unit-Must reside in Kentucky

Molina Healthcare • Louisville, KY

95d • $69,447 - $142,548

About The Position

Establish a specifically designed compliance program that effectively prevents and/or detects violation of applicable laws and regulations, which will protect the Business from liability of fraudulent or abusive practices. Ensures that the Business understands and complies with applicable laws and regulations pertaining to the Health Care environment. Ensures the Business' accountability for compliance by overseeing, follow-up and resolution of investigations.

Requirements

• Bachelor's Degree or equivalent combination of education and experience.
• 5-7 years of relevant experience.
• Active and unrestricted Accredited Health Care Fraud Investigator (AHFI) designation or Certified Fraud Examiner (CFE).

Nice To Haves

• Master's Degree preferred; will consider previous experience in health plan setting in government programs.
• 7-9 years of relevant experience.
• Health Care Anti-Fraud Associate (HCAFA) designation.

Responsibilities

• Provides oversight and review of the SIU referral intake and investigation process while giving guidance and direction to team on case investigation steps and actions.
• Works with leadership to maintain and revise policies and procedures, fraud, waste, and abuse plans, annual audit work plans, including department guidance memos, and educational materials.
• Identifies opportunities for improvement through the audit process and provide recommendations for system enhancement to augment investigative outcomes and performance.
• Accurately tracks, reports, and follows up on overpayments and recoveries.
• Leads business requirement process and reporting to ensure proper and timely notification of case activity to the appropriate regulatory and/or law enforcement agency.

Benefits

• Competitive benefits and compensation package.

What This Job Offers

• Industry: Insurance Carriers and Related Activities
• Education Level: Bachelor's degree