Special Investigative Unit Investigator

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Special Investigative Unit Investigator
Duties: Ensure that the compliance department meets the required OIG effective compliance program elements by promptly responding to identified issues and concerns within the organization. Ensuring that these issues are being appropriately evaluated, investigated, and resolved. Respond to alleged violations of rules, regulations, policies, procedures, and Code of Conduct by evaluating or recommending the initiation of investigative procedures. Ensure policies and procedures are followed for the general operation of the compliance program and its related activities to prevent illegal, unethical, or improper conduct. Conduct interviews with providers, employees, members and witnesses as part of the investigative process. Consult with various levels of leadership to resolve complex compliance issues. Ability to present investigation summaries that include metrics, trends and schemes to various committees. Maintain a monitoring system, which tracks, trends and oversees compliance issues or violations. Facilitates the recovery of company and customer money lost as a result of fraud matters. Under the direction of management, develop and implement corrective action plans for resolution of non-compliant issues, and provide general guidance on how to avoid or deal with similar situations in the future. Identify potential areas of compliance vulnerability and risk and provide recommendations to management to address the issues. Support ongoing activities relating to Compliance. Demonstrated knowledge of Managed Care products such as Medicare, Medicaid, ACA and FEHBP as well as commercial insurance. Maintain current knowledge of health care legislation and regulations on both the state and federal level. Work independently and manage a caseload that include investigations, identifying schemes, tracking, trending and reporting instances of noncompliance. Develop and facilitate training regarding Fraud Waste and Abuse requirements, Non-retaliation policy, Code of Conduct and government program requirements.

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