Special Investigation Unit Manager

South Florida Community Care Network•Sunrise, FL

7d•Hybrid

About The Position

The Special Investigations Unit Manager is responsible for performing elements of the Fraud, Waste & Abuse (FWA) Program in compliance with contractual and regulatory requirements. The Special Investigations Unit Manager responsibilities include but are not limited to program integrity, case management, case investigation, overpayment recoveries, reporting of investigations to regulatory agencies, responding to government requests for information related to FWA, facilitating compliance with state and federal FWA requirements, and identifying new cases and recovery opportunities.

Requirements

Must hold a bachelor's degree.
Minimum of 5–7 years of experience in a healthcare program integrity role ensuring compliance with regulatory and contractual requirements.
Expertise in healthcare fraud and abuse prevention, detection, and investigative processes, with the ability to design, implement, and oversee a fraud and abuse program.
Knowledge of healthcare fraud, waste, and abuse (FWA) methodologies, investigative approaches, and applicable regulations.
Healthcare industry and/or Medicaid/CHIP knowledge.
Must be able to travel, as business needs require, for quarterly Medicaid Program Integrity (MPI ) meetings and other organizational meetings.
Travel is typically one (1) to three (3) consecutive days per occurrence.
Must hold a nationally recognized anti-fraud certification , such as Accredited Health Care Fraud Investigator (AHFI) and/or Certified Fraud Examiner (CFE) Or the ability to achieve a nationally recognized anti-fraud certification within 1 year/12 months of employment
Proficiency with Microsoft Office applications, including advanced Microsoft Excel
Knowledge of current FWA trends, emerging schemes, and issues of interest to law enforcement and regulatory agencies
Ability to work independently with minimal supervision while managing a high volume of assignments.
High degree of integrity and ability to maintain confidentiality when handling sensitive and protected information.
Strong analytical, deductive reasoning, and problem-solving skills with the ability to think logically and sequentially.
Strong verbal and written communication skills.
Knowledge of internal and external resources used to support fraud investigations.
Ability to communicate effectively, verbal and written
Ability to self-motivate
Strong time management skills
Ability to prioritize and organize FWA program activities
Ability to meticulously document case actions and findings for regulatory reporting and any legal action, if applicable
Ability to collaborate
Results oriented skills

Nice To Haves

Healthcare claims knowledge and experience.
Medical terminology knowledge and/or experience with CPT and ICD-10 coding.

Responsibilities

Accountable for establishing and maintaining a relationship with AHCA-Medicaid Program Integrity as part of CCP’s Medicaid FWA program, including but not limited to attendance at collaborative meetings and responding to AHCA-MPI inquiries.
Oversee the Managed Care Plan’s fraud and abuse detection and prevention efforts and work with Medicaid Program Integrity and the Medicaid Fraud Control Unit.
Ensures compliance with all state and federal requirements related to FWA and FWA investigations.
Performs data-mining activities to identify potential cases for investigation.
Analyzes data as part of the investigative process.
Performs research to analyze aberrant claims billing and practice patterns.
Investigates and documents all fraud, waste, and abuse referrals and cases with a focus on thoroughness and attention to detail, quality, timeliness, and cost control.
Conducts comprehensive interviews with providers, members, and witnesses to obtain information which would be considered admissible under generally accepted criminal and civil rules of evidence.
Coordinates with subcontractors on investigations, reporting and recovery of FWA.
Collaborates with Compliance team members as needed on case elements.
Prepares and submits investigative reports covering all phases of the investigation.
Prepares and sends audit findings to providers.
Interprets and conveys information to others, including but not limited to regulatory requirements, AHCA and/or Florida Healthy Kids requirements, and provider contract requirements.
Establishes and maintains liaison with public officials, law enforcement and others to obtain assistance in conducting investigations.
Other duties as directed based on business needs, department priorities.
Employees will be required to perform any other job-related duties assigned by their supervisor or management.