Special Investigations Unit Manager

CareOregon

1d•Remote

About The Position

This position manages and administers fraud, waste and abuse (FWA) for CareOregon and two wholly-owned Coordinated Care Organizations (CCOs) – Columbia Pacific CCO (CPCCO) and Jackson Care Connect CCO (JCC CCO). This includes leading, overseeing and/or performing fraud investigations and providing regular FWA reporting to all CareOregon CCOs. Additionally, this position manages internal staff and provides FWA oversight for Third-Party Administrative (TPA) activities CareOregon performs on behalf of the Health Share CCO.

Requirements

As required by our Medicaid contract, the individual must be a professional investigator, paralegal, professional coder, or auditor with corresponding certification
Minimum 5 years’ experience in compliance and/or audit, including minimum 2 years focused on fraud, waste, and abuse
Knowledge Advanced understanding of healthcare fraud, waste and abuse
Strong knowledge of State and Federal compliance and FWA requirements for Medicare and Medicaid Programs
Strong knowledge of investigative techniques, including interviews, data analytics, evidence gathering, case documentation
Solid understanding of information and reporting systems
Knowledge about how the functions of a business work and relate to one another to benefit the member by improving regulatory compliance
Excellent written and verbal communication skills
Strong research, investigative and problem-solving skills
Strong interpersonal and motivational skills
People leadership skills, including the ability to manage and coach team members
Ability to facilitate learning opportunities in a variety of informal and formal settings
Ability to make presentations to small and large groups
Ability to think logically and creatively without undue influence from personal biases
Ability to build conceptual models and communicate complex ideas effectively
Ability to plan, organize, manage, and monitor work projects
Ability to serve in an internal consulting role, assisting the organization’s management and staff in embracing our goal of “doing it right the first time” and being cognizant of the company’s commitments to its various partners and the need to achieve excellent results in our work product and processes
Ability to work effectively with diverse individuals and groups
Ability to learn, focus, understand, and evaluate information and determine appropriate actions
Ability to accept direction and feedback, as well as tolerate and manage stress
Ability to see, read, and perform repetitive finger and wrist movement for at least 6 hours/day
Ability to hear and speak clearly for at least 3-6 hours/day

Nice To Haves

Minimum 2 years’ experience in a supervisory position or minimum 1 year experience in a supervisory position with completion of CareOregon’s Aspiring Leaders Program
Fraud, waste and abuse experience in Medicaid or Medicare

Responsibilities

Manage the development and operation of an effective fraud, waste, and abuse program in accordance with CMS requirements and the Federal Sentencing Guidelines with guidance from department leadership, including: Recommendation and implementation of FWA policies and the FWA annual plan, Periodic reporting to the organization’s Internal Compliance Committee and governing Board of Directors, Effective training and education, Establishment and maintenance of effective lines of communication at all levels of the organization (to include a non-compliance reporting hotline), Development and oversight of effective system for routine FWA monitoring, auditing and identification of compliance risks, Collaboration with other departments to ensure compliance issues are reported to appropriate channels for investigation and resolution, Clear and specific policies, procedures and standards relating compliance monitoring activities.
Ensure the timely completion of the annual FWA work plan and evaluate the corresponding work performed by department staff.
Perform and manage FWA investigations conducted by CareOregon staff, affiliates, and business partners.
Complete and file all required Medicare and Medicaid filings and/or responses for FWA.
Manage the development of sufficient and accurate monthly FWA dashboards and corresponding summaries used to identify and monitor current compliance and trending of all FWA matters including case details and metrics.
Identify potential areas of FWA vulnerability and risk; partner with department leadership in developing and implementing corrective action plans for resolution of problematic issues and provide general guidance on how to avoid or deal with similar situations in the future.
Provide input into strategic planning and budget planning for the department.
Manage team and recommend team direction and goals in alignment with the organizational mission, vision, and values.
Identify work and staffing needs to meet work expectations; recruit and hire, using an equity, diversity, and inclusion lens.
Plan, organize, schedule, and monitor work; ensure employees have information and resources to meet job expectations.
Lead the development, communication, and oversight of team and individual goals; ensure goals, expectations, and standards are clearly understood by staff.
Train, supervise, motivate, and coach employees; provide support toward employee development.
Incorporate guidance from CareOregon equity tools into people leadership, planning, operations, evaluation, and decision making.
Ensure team adheres to department and organizational standards, policies, and procedures.
Evaluate employee performance and provide regular feedback to support success; recognize strong performance and address performance gaps and accountability (corrective action).
Perform supervisory tasks in collaboration with Human Resources as needed.

Benefits

competitive pay
bonus opportunity
medical insurance
dental insurance
vision insurance
life insurance
AD&D insurance
disability insurance
health savings account
flexible spending account(s)
lifestyle spending account
employee assistance program
wellness program
discounts
multiple supplemental benefits (e.g., voluntary life, critical illness, accident, hospital indemnity, identity theft protection, pre-tax parking, pet insurance, 529 College Savings, etc.)
strong retirement plan with employer contributions
Paid State Sick Time
paid holidays
volunteer time
jury duty
bereavement leave