For more information and to apply, please visit https://recruiting.adp.com/srccar/public/RTI.home?c=2165301&d=External&r=5000962436706&_fromPublish=true#/

Primary Purpose:
Performs oversight of the Special Investigations Unit (SIU) Investigators to ensure thorough investigations, prompt resolution and compliance with regulatory requirements; develops and delivers training, policies and procedures; detects, corrects and prevents FWA; and supports SIU operations, process improvements, project implementation, audits and arbitration.

Minimum Requirements:

1. Bachelor's degree and four years of related work experience in audit; legal; clinical practice; health plan operations, administration, and/or contracting; special (healthcare FWA) investigation; and/or criminal justice or equivalent combination of education and experience.
2. Understanding of claim billing codes, medical terminology, and health care delivery systems
3. Proven ability to research and interpret regulatory requirements and medical coding to ensure compliance.
4. Basic working knowledge of Microsoft Outlook and PowerPoint.
5. Intermediate working knowledge of Microsoft Word and Excel.

1. Investigator Team Leadership and Support:
   • Perform Investigator staff oversight, and coaching on day-to-day investigation activities including, but not limited to FWA case reviews and approvals, regulatory referrals, documentation, reporting, overpayment processing and prevention.
   • Facilitate and lead Investigator-level meetings to resolve operational issues, brainstorm FWA prevention opportunities, provide clarification and discuss relevant FWA topics.
   • Develop and deliver trainings, materials, tools and templates to support SIU processes and enhance the knowledge and skills of FWA investigators including emerging trends, awareness of fraud schemes and investigative techniques.
2. SIU Operations:
   • Develop and/or enhance FWA policies, procedures and guidelines for Investigative staff based on industry best practices, evolving fraud detection methodologies and regulatory requirements and laws impacting SIU operations.
   • Identify and act on opportunities for process improvement, leveraging technology to enhance investigative efficiency, effectiveness and outcomes.
   • 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.
   • Perform vendor and vendor manager oversight, training and guidance to meet HMSA's FWA regulatory and reporting requirements.
3. FWA Detection, Investigation, 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.
4. Audits, Arbitration and Regulatory Requirements
   • Lead SIU related internal and external audit deliverables by collecting and coordinating evidence, and responses.
   • Represent the SIU for audit and regulatory interviews and meetings.
   • Participate in arbitration as applicable for impacted FWA cases.
   • Lead implementation of new or revised regulatory requirements or laws impacting the SIU.
5. Performs all other miscellaneous responsibilities and duties as assigned or directed