Manager, Special Investigative Unit(Texas)

Molina Healthcare•Long Beach, TX

About The Position

Leads and manages a team responsible for Special Investigation Unit (SIU) activities, specifically the prevention and detection of violations of applicable laws and regulations. This role is responsible for protecting the business from liability of fraudulent or abusive practices and ensuring the business understands and complies with applicable laws and regulations pertaining to the health care environment. The position is accountable for the oversight, follow-up, and resolution of investigations.

Requirements

At least 7 years of experience in special investigations, law enforcement, and/or experience in a regulatory environment, or equivalent combination of relevant education and experience.
At least 1 year of management/leadership experience.
Strong interpersonal skills.
Strong analytical and critical-thinking abilities.
Organizational and time-management skills.
Experience with investigative case management system.
Strong verbal and written communication skills.
Microsoft Office suite/applicable software program(s) proficiency.

Nice To Haves

Health Care Anti-Fraud Associate (HCAFA), Accredited Health Care Fraud Investigator (AHFI) and/or Certified Fraud Examiner (CFE).

Responsibilities

Provides oversight and review of the special investigation unit (SIU) referral intake and investigation process, and provides guidance and direction to team on case investigation steps/actions.
Collaborates with leadership to maintain and revise policies and procedures, fraud, waste, and abuse (FWA) plans, annual audit work plans - including department guidance memos, and educational materials.
Identifies opportunities for improvement through the audit process and provides recommendations for system enhancements in order 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.