Job Description

1. SIU case investigation management, resolution and prevention:
   
   • Manage complex FWA case investigations, collaborate with federal, state and law enforcement entities, and provide applicable notifications as required.
   • Conduct pro-active FWA case investigations and resolutions.
   • Maintain extensive documentation and evidence for SIU cases.
   • Recommend and implement preventive measures to combat FWA schemes including, but not limited to provider education, policies, claims edits and payment suspensions.
   • Conduct and lead on-site provider audits and interviews to support complex FWA case investigations.
   • Manage the recovery, allocation and documentation of health plan funds resulting from FWA findings.
2. Support SIU Operations:
   
   • Create and maintain internal policies and procedures, workflows and presentations and present as needed to internal and external entities.
   • Coordinate and manage regulatory audit requests and RFIs from law enforcement and federal and state entities.
   • Represent SIU at cross functional workgroups and meetings and present case recommendations and preventive solutions to Management and other applicable business areas including, but not limited to Legal, Medical Management, Provider Operations and Claims Operations.
   • Provide operational oversight to SIU Vendors with delegated FWA functions.
   • Create and/or refresh and present SIU training to HMSA employees, employer groups, vendors and other business areas as needed.
3. SIU allegation intake and management:
   
   • Manage the intake, documentation and resolution of FWA referrals to SIU.
   • Coordinate with internal and external partners on FWA allegations.
   • Assess needs, make recommendations and complete timely reviews in accordance with all regulatory requirements.
4. Perform all other miscellaneous responsibilities and duties as assigned or directed.

1. Bachelor's degree and two years of related work experience; or equivalent combination of education and related work experience.
2. Fundamental knowledge/awareness of Fraud, Waste and Abuse.
3. Strong oral and written communication skills.
4. Knowledge of health care investigations.
5. Intermediate working knowledge of Microsoft Word, Excel, PowerPoint, and Outlook.