Manager Special Investigation Unit

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Manager, Special Investigation Unit
Duties: Manages a team in the Special Investigations Unit to detect, investigate, remediate and refer to state regulatory agencies and/or law enforcement as appropriate, incidents of fraud, waste and abuse (FWA) arising in connection with medical, behavioral, dental, transportation, pharmacy, and other healthcare services. Accountable for all investigations conducted by his/her team and will provide oversight and approval of the investigations from the planning phase through the disposition. This position is dedicated to Community’s lines of business (CHIP, Medicaid, Commercial), and oversees all aspects of FWA within those segments. Determine correct coding, review claims, review medical records, and billing data from all types of healthcare providers for aberrant billing patterns. Managing case assignments, case development, case review, overpayment recoveries, managing RFIs, state agency and/or law enforcement referrals, training of staff, and coordination with other departments to mitigate and remedy FWA. Developing, implementing and managing strategic FWA activities by maintaining state and federal requirements and monitoring trends and schemes.

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