Job Description

Manager Special Investigations Unt (SIU MANSGER) Onsite Houston, Texas, United States.. 12 Month Minimum Mgr Special Investigations Unt 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. Keywords: 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 yr experience working with medicaid One of the below certifications are Required- CPA - Cert-Cert Public Accountant- Relevant state board of public accountancy CFA - 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 Publishing Information Manager Special Investigation: On behalf of our healthcare client, Procom is searching for a Manager Special Investigation for a permanent role. This position is onsite at our client's Houston, Texas office. Manager Special Investigation - Job Description: The Manager Special Investigation will oversee the Special Investigations Unit (SIU) and Fraud, Waste & Abuse (FWA) Program, ensuring compliance with contractual and regulatory requirements. The role involves managing case investigations, overpayment recoveries, and reporting to regulatory agencies, while also developing employee education and identifying new recovery opportunities. Manager Special Investigation - Responsibilities: Coordinate with subcontractors on overseeing investigations of Fraud, Waste & Abuse (FWA). Manage a large fraud investigation caseload and investigate allegations related to healthcare fraud. Provide case updates and recommendations in coordination with SIU team members and other departments. Interface with members, vendors, and other third parties to further and conclude investigations. Implement processes to prevent, detect, investigate, and report FWA to regulatory agencies. Provide inter-departmental input regarding controls for preventing and monitoring FWA issues. Identify trends and aberrant activity to generate leads for FWA investigations. Perform special assignments related to FWA as assigned by the Director of Controls and Compliance. Manager Special Investigation - Mandatory Skills: Strong analytical and research skills. Experience in fraud, waste & abuse (FWA) investigations or special investigations unit (SIU). Knowledge of medical terminology and experience with CPT codes, ICD-9, and ICD-10 coding. Strong communication and customer service skills. Certification in CPA, CFA, AHFI, or INT-POPC. Experience working with Medicaid. Ability to exercise independent judgment and use technology in investigations. Manager Special Investigation Nice-to-Have Skills: Knowledge of suspected FWA trends and matters of interest to law enforcement and regulators. Experience with a Health Plan and understanding of SIU components and functions. Proficiency in identifying information resources. Problem-solving skills. Teamwork-oriented mindset.

Job Tags

Permanent employment, For subcontractor, Work at office,

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