Job Description

1. Perform FWA incident oversight and SIU staff development activities:
   
   • Provide direct oversight to other SIU staff by reviewing and providing feedback to Investigators for written correspondences and regulatory referrals.
   • Provide day-to-day advice/guidance to SIU staff on FWA incidents including decisions to open and/or close SIU incidents.
   • Create, update and present training sessions for all SIU staff, internal and external entities covering special investigations workflows and processes, information and data systems, and subject-matter specific topics (e.g., specialized information sessions about medical/coding topics and FWA trends/schemes; Special Investigation case studies).
2. SIU case investigation management, resolution and prevention.
   
   • Initiate, analyze, develop, and resolve proactive FWA cases using Fraud Detection Software, advance/extensive knowledge of benefits, claims, rules, processes, and other relevant topics (e.g., medicine, pharmacy, law, accounting).
   • 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.
3. SIU Process Improvement and SIU Operational Support
   
   • Perform necessary research and analysis, and recommend improvements and corrective actions for contract, policy, claim-level, and workflow problems proactively identified in case work and other assigned tasks.
   • Independently ensures that SIU's needs are being addressed; must be able to clearly articulate business needs so that the department is not negatively affected and elevate concerns and issues to management when applicable.
   • Create and maintain internal policies and procedures, workflows and presentations and present as needed to internal and external entities.
   • Participate in management discussions to improve business processes and control structures.
   • 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.
4. Perform all other miscellaneous responsibilities and duties as assigned or directed.

1. Bachelor's degree and three years of work experience in audit; legal; clinical practice; health plan operations, administration, and/or contracting; special (healthcare FWA) investigation; and/or criminal justice experience or equivalent combination of education and experience.
2. Prior experience operating in a regulated environment involving compliance with federal, state, and local laws and regulations, and/or corporate policies and procedures.
3. Strong understanding of Fraud, Waste and Abuse schemes and scams.
4. Strong oral and written communication skills.
5. Strong understanding of health care investigations.
6. Proficient business, legal, and/or medical research skills.
7. Intermediate working knowledge of Microsoft Word, Excel, Outlook, and PowerPoint.