Special Investigation Unit Manager

South Florida Community Care Network LLC

Fort Lauderdale, FL, USA

Published: 6/14/2022

Legal

Full Time

Job Description

Hybrid- Sunrise Florida

Health Care FWA investigations Experience-Required

Position Summary:

The Special Investigation Unit Manager is responsible for the Fraud, Waste & Abuse (FWA) Program in compliance with contractual and regulatory requirements. The Special Investigation Unit Manager responsibilities include but are not limited to 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.

Essential Duties and Responsibilities:

Accountable for managing the day-to-day activities of the FWA Program, reporting to the Manager, Compliance & SIU.
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.
Prepares and submits investigative reports covering all phases of the investigation.
Interprets and conveys highly technical information to others.
Establishes and maintains liaison with public officials, law enforcement and others to obtain assistance in conducting investigations.

This job description in no way states or implies that these are the only duties performed by the employee occupying this position. Employees will be required to perform any other job-related duties assigned by their supervisor or management.

Qualifications:

Bachelor level education
Five (5) to seven (7) years’ experience conducting comprehensive health care FWA investigations; interacting with state, federal and local law enforcement agencies.
Ability to work independently with minimal supervision and manage a high volume of assignments.
High degree of integrity and confidentiality required handling information that is considered personal and confidential
Analytical skills and ability to make deductions; logical and sequential thinker
Strong verbal and written communication skills.
Health care industry and/or Medicaid/CHIP knowledge required
Advanced knowledge and experience working on various approaches to health care fraud, waste, and abuse
Working knowledge of Microsoft applications, especially Excel required
Knowledge of available resources (internal and external) to assist in investigations
Medical terminology knowledge and/or experience with CPT and ICD-10 coding preferred.
Knowledge of suspected FWA trends, potential schemes, and matters of interest to law enforcement and regulators
Accredited Health Care Fraud Investigator (AHFI) and/or Certified Fraud Examiner (CFE) preferred

SKILLS AND ABILITIES:

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

PHYSICAL DEMANDS:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to sit, use hands, reach with hands and arms, and talk or hear. The employee is frequently required to stand, walk, and sit. The employee is occasionally required to stoop, kneel, crouch or crawl. The employee may occasionally lift and/or move up to 15 pounds.

We are an equal opportunity employer who recruits, employs, trains, compensates and promotes regardless of age, color, disability, ethnicity, family or marital status, gender identity or expression, language, national origin, physical and mental ability, political affiliation, race, religion, sexual orientation, socio-economic status, veteran status, and other characteristics that make our employees unique. We are committed to fostering, cultivating, and preserving a culture of diversity, equity, and inclusion.

Work Environment:

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of the job. The environment includes work inside/outside the office, travel to other offices, as well as domestic, travel. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The noise level in the work environment is usually moderate.