Mgr Special Investigations Unt

Job Title: Manager, Special Investigations Unit
Job Location: Houston, TX 77401
Job Duration: 3 months

Job Description:
Duties:
Responsible for the oversight of the Special Investigations Unit (SIU) and Fraud, Waste & Abuse (FWA) Program in compliance with contractual and regulatory requirements. Oversees case management, case investigation, overpayment recoveries, reporting of investigations to regulatory agencies; responds to government requests for information related to FWA; facilitates compliance with state and federal FWA requirements; develops and maintains employee education; and identifies new recovery opportunities, goals and sound practices.

• Coordinates with subcontractors on overseeing investigations of Fraud, Waste & Abuse (FWA).
• Manages a large fraud investigation caseload and investigates allegations relating to potential health care fraud perpetrated by Medicaid and commercial providers, vendors and enrollees.
• Provides internal and external case updates on progression of investigations in coordination with SIU team members and other departments, including recommendations on further action and/or resolution, as needed.
• Continually interfaces with members, vendors, pharmacies, providers and other third parties via telephone, e-mail, and on-site visits as needed to identify, further, and conclude ongoing investigations.
• Implements processes and procedures to: prevent, detect, investigate and report FWA to appropriate regulatory agencies.
• Provides inter-departmental input regarding controls for preventing and monitoring FWA issues.
• Proactively identifies trends and aberrant activity to generate leads for FWA investigations.
• Performs special assignments related to FWA as assigned by the Director of Controls and Compliance.

Special Investigations Unit (SIU) experience with a Health Plan and understands the components and functions of an SIU.

Skills:

• Strong analytical and research skills. Proficient in researching information and identifying information resources.
• Exercises independent judgement and uses available resources and technology in developing evidence and supporting allegations of fraud, waste and abuse.
• Knowledge of medical terminology and/or experience with CPT codes, and ICD-9, ICD-10 coding.
• Knowledge of suspected FWA trends and matters of interest to law enforcement and regulators.
• Strong communication and customer service skills.

Education:

• Required: H.S. Diploma or GED or Bachelor's Degree
• Required: 8 years - experience in Fraud, Waste & Abuse (FWA) investigations or Special Investigations Unit (SIU) including 1 year experience working with Medicaid

One of the below certifications are required:

• CPA - Certified Public Accountant - Relevant state board of public accountancy
• CFE - Certified Fraud Examiner- Association of Certified Fraud Examiners
• AHFI - Accredited Health Care Fraud Investigator - NHCAA National Health Care Anti Fraud Association
• INT-POPC Intermediate Peace Officer Proficiency Certificate - Intermediate Peace Officer Proficiency Certificate