Special Investigation Unit Manager

Job Description

Job Description

Position Summary:

The Special Investigations Unit Manager is responsible for performing elements of the Fraud, Waste & Abuse (FWA) Program in compliance with contractual and regulatory requirements. The Special Investigations Unit Manager responsibilities include but are not limited to program integrity, case management, case investigation, overpayment recoveries, reporting of investigations to regulatory agencies, responding to government requests for information related to FWA, facilitating compliance with state and federal FWA requirements, and identifying new cases and recovery opportunities.

Essential Duties and Responsibilities:

1. Accountable for establishing and maintaining a relationship with AHCA-Medicaid Program Integrity as part of CCP’s Medicaid FWA program, including but not limited to attendance at collaborative meetings and responding to AHCA-MPI inquiries.
2. Oversee the Managed Care Plan’s fraud and abuse detection and prevention efforts and work with Medicaid Program Integrity and the Medicaid Fraud Control Unit.
3. Ensures compliance with all state and federal requirements related to FWA and FWA investigations.
4. Performs data-mining activities to identify potential cases for investigation.
5. Analyzes data as part of the investigative process.
6. Performs research to analyze aberrant claims billing and practice patterns.
7. Investigates and documents all fraud, waste, and abuse referrals and cases with a focus on thoroughness and attention to detail, quality, timeliness, and cost control.
8. Conducts comprehensive interviews with providers, members, and witnesses to obtain information which would be considered admissible under generally accepted criminal and civil rules of evidence.
9. Coordinates with subcontractors on investigations, reporting and recovery of FWA.
10. Collaborates with Compliance team members as needed on case elements.
11. Prepares and submits investigative reports covering all phases of the investigation.
12. Prepares and sends audit findings to providers.
13. Interprets and conveys information to others, including but not limited to regulatory requirements, AHCA and/or Florida Healthy Kids requirements, and provider contract requirements.
14. Establishes and maintains liaison with public officials, law enforcement and others to obtain assistance in conducting investigations.
15. Other duties as directed based on business needs, department priorities.

This job description in no way states or implies that these are the only duties performed by the employee occupying this position. Employees will be required to perform any other job-related duties assigned by their supervisor or management.

Qualifications:

Required Qualifications

• Must hold a bachelor's degree.
• Minimum of 5–7 years of experience in a healthcare program integrity role ensuring compliance with regulatory and contractual requirements.
• Expertise in healthcare fraud and abuse prevention, detection, and investigative processes, with the ability to design, implement, and oversee a fraud and abuse program.
• Knowledge of healthcare fraud, waste, and abuse (FWA) methodologies, investigative approaches, and applicable regulations.
• Healthcare industry and/or Medicaid/CHIP knowledge.
• Must be able to travel, as business needs require, for quarterly Medicaid Program Integrity (MPI ) meetings and other organizational meetings. Travel is typically one (1) to three (3) consecutive days per occurrence.
• Must hold a nationally recognized anti-fraud certification , such as Accredited Health Care Fraud Investigator (AHFI) and/or Certified Fraud Examiner (CFE)
  • Or the ability to achieve a nationally recognized anti-fraud certification within 1 year/12 months of employment

Preferred Qualifications

• Healthcare claims knowledge and experience.
• Medical terminology knowledge and/or experience with CPT and ICD-10 coding.

Additional Qualifications

• Proficiency with Microsoft Office applications, including advanced Microsoft Excel
• Knowledge of current FWA trends, emerging schemes, and issues of interest to law enforcement and regulatory agencies
• Ability to work independently with minimal supervision while managing a high volume of assignments.
• High degree of integrity and ability to maintain confidentiality when handling sensitive and protected information.
• Strong analytical, deductive reasoning, and problem-solving skills with the ability to think logically and sequentially.
• Strong verbal and written communication skills.
• Knowledge of internal and external resources used to support fraud investigations.

SKILLS AND ABILITIES:

• Ability to communicate effectively, verbal and written
• Ability to self-motivate
• Strong time management skills

• Ability to prioritize and organize FWA program activities
• Ability to meticulously document case actions and findings for regulatory reporting and any legal action, if applicable
• Ability to collaborate
• Results oriented skills

Work Schedule:

Community Care Plan is currently following a hybrid work schedule. The company reserves the right to change the work schedules based on the company needs.

PHYSICAL DEMANDS:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to sit, use hands, reach with hands and arms, and talk or hear. The employee is frequently required to stand, walk, and sit. The employee is occasionally required to stoop, kneel, crouch or crawl. The employee may occasionally lift and/or move up to 15 pounds.

We are an equal opportunity employer who recruits, employs, trains, compensates and promotes regardless of age, color, disability, ethnicity, family or marital status, gender identity or expression, language, national origin, physical and mental ability, political affiliation, race, religion, sexual orientation, socio-economic status, veteran status, and other characteristics that make our employees unique. We are committed to fostering, cultivating and preserving a culture of diversity, equity and inclusion.

Work Environment:

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of the job. The environment includes work inside/outside the office, travel to other offices, as well as domestic travel. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The noise level in the work environment is usually moderate.

Background Screening Notice: In compliance with Florida law, candidates selected for this position must complete a Level 2 background screening through the Florida Care Provider Background Screening Clearinghouse.

The Clearinghouse is a statewide system managed by the Agency for Health Care Administration (AHCA) and is designed to help protect children, seniors, and other vulnerable populations while streamlining the screening process for employers and applicants.

Additional information is available at:
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