Location: Rockledge,FL, USA
POSITION SUMMARY
Oversee and manage the Special Investigations Unit in an effective and engaging manner with our Health Plan Accountable for development, implementation and management of strategic fraud, waste and abuse (FWA) activities by maintaining state, and federal requirements and monitoring trends and schemes. The manager must have the ability to determine correct coding, review claims, review medical records, and billing data from all types of healthcare providers for aberrant billing patterns. Duties include managing case assignments, case development, case review, overpayment recoveries, state agency and/or law enforcement referrals, training of staff and coordination with other Integrated Delivery Network (IDN) departments to mitigate and remedy fraud, waste and abuse.
PRIMARY ACCOUNTABILITIES
* Maintain a working relationship with regulators and law enforcement including; local, state and federal law enforcement; Department of Insurance Fraud Bureaus; the Federal Bureau of Investigations; CMS Investigative Unit; and other agencies.
* Responsible for all aspects of the Corporate Compliance program for the Special Investigation Unit entities, including design, implementation, administration, policies and procedures and reporting all of which are in keeping with regulatory guidance.
* Receive, log, and thoroughly documents all incoming FWA complaints, incidents and leads.
* Conducts field operations to include surveillance as required.
* Prepare executive summaries and/or detailed reports on investigative findings for referral to Federal and state agencies to include, but not limited to, the MEDIC, DOI, FBI, HHS-OIG, MFCU, and local law enforcement.
* Responsible to meet all regulatory and departmental deadlines.
* Manage and participate in all audits by outside professional firms, government and regulatory agencies.
* Perform data mining and analysis to detect claims aberrancies/provider outliers.
* Coordinate audits of claims, including probe and full statistical samples utilizing either random or targeted methodologies.
* Drive recoveries, prevention and cost avoidance.
* Develop and conduct Compliance and FWA education programs to respond to associate, management, first tier and downstream entities.
* Contact members, providers, and third parties to validate services.
LEADERSHIP ACCOUNTABILITIES
* Define and communicate a clear, compelling vision for the team that effectively ties into the mission and vision of Health First, and inspirationally leads the team to achieve that vision.
* Provide leadership, motivation, coaching, feedback and support to strengthen growth, development and wellness at work to build and foster effective, high performing teams.
* Lead change through effective communication, explaining the connection and value to the organization, creating stronger buy-in and urgency, while understanding impact to the team to obtain commitment.
* Demonstrate openness to hearing diverse ideas and thoughts; create a sense of inclusivity; and encourage collaboration across teams to help break down silos to meet the team's and organization's goals.
* Recruit, select, grow, and retain highly engaged, high performing diverse and inclusive associates.
* Demonstrate fiscal acumen and contribute to and support the strategic direction of the areas of responsibility and organization.
MINIMUM QUALIFICATIONS
* Education: Bachelor's degree in related field, healthcare administration, business administration, criminal justice, legal studies or management.
* Licensure: None
* Certification: None
* Work Experience:
* 7 years' combined medical claim investigation, financial impact analysis, business analysis, compliance or fraud and abuse experience.
* 2 years' supervisory experience.
* Work Experience in lieu of Education: Additional four (4) years in Federal or State Healthcare programs, or progressive investigation operational experience.
* Knowledge/Skills/Abilities:
* Strong knowledge and proficiency in health care claims processing, medical coding, and data mining.
* Excellent interpersonal, written and oral presentation skills.
* Proficient in Microsoft Office
* Ability to build relationships with internal/external departments and regulatory agencies.
* Excellent skills in performing comprehensive legal and regulatory research and analysis.
PREFERRED QUALIFICATIONS
* Education: No additional
* Licensure: No additional
* Certification: Accredited Healthcare Fraud Investigator (AHFI), Certified Fraud Examiner (CFE), Certified Professional Coder (CPC), Registered Nurse (RN) or other position related certification.
* Work Experience: Experience working with both Commercial and Medicare health insurance products and regulations.
* Knowledge/Skills/Abilities: Advanced level proficiency with Microsoft Excel.
PHYSICAL REQUIREMENTS
* Majority of time involves sitting or standing; occasional walking, bending, stooping.
* Long periods of computer time or at workstation.
* Light work that may include lifting or moving objects up to 20 pounds with or without assistance.
* May be exposed to inside environments with varied temperatures, air quality, lighting and/or low to moderate noise.
* Communicating with others to exchange information.
* Visual acuity and hand-eye coordination to perform tasks.
* Workspace may vary from open to confined; on site or remote.
* May require travel to various facilities within and beyond county perimeter; may require use of personal vehicle.