| Summary: The Special Investigations Unit (SIU) Manager is responsible for oversight of all aspects of MVP’s Fraud, Waste & Abuse (FWA) Prevention Program. The SIU Manager develops and administers a strategy that maximizes opportunities to drive FWA savings, including identifying new opportunities, goals and sound practices. Areas of responsibility include: management of the SIU Department, development and implementation of the FWA Prevention Program, investigation of potential FWA cases, reporting of relevant data internally and externally, facilitating compliance with federal and state FWA requirements and the development and maintenance of employee education and awareness. 1. Facilitates compliance with federal and state FWA requirements, including CMS, OMIG, DOH and DFS. 2. Develops annual FWA Audit Plan and presents plan to the Corporate Compliance Committee for approval. 3. Hires, trains, coaches, counsels and evaluates the performance of direct reports. 4. Reviews all referral sources (including data mining) and develops and implements staffing resource plan to address referrals as well as outliers. 5. Proactively uses analytical skills to identify potential areas of FWA, including areas of risk to MVP and develops and implements an auditing and monitoring plan to address high risk areas. 6. Investigates, collects, researches and analyzes data in order to detect fraudulent, abusive or wasteful activities/practices. 7. Prepares and presents written reports of findings and recommendations regarding FWA investigations and takes further administrative action if warranted, including presentation to medical directors and/or referrals to regulatory agencies including, but not limited to, the FBI, DFS, OMIG, DOH, AG MFCU, HHS-OIG, CMS and local law enforcement. 8. Responsible for overseeing and evaluating delegated entities’ FWA programs. 9. Plans, implements, promotes and maintains a company-wide employee education strategy to increase employee awareness of the SIU, and the indicators of potential fraud, waste and abuse. 10. Conducts meetings with providers, vendors, MVP employees and when appropriate, representatives from regulatory agencies. 11. Creates provider education and corrective action plans. 12. Prepares and presents (as necessary) all relevant SIU reports demonstrating the results of MVP’s FWA Audit Plan. 13. Develops and oversees SIU’s budget. 14. Develops and maintains a high degree of rapport and cooperation with federal, state and local law enforcement and regulatory agencies which can assist in investigative efforts. 15. Keeps abreast of all current and upcoming legislation directives. 16. Participates in the National Health Care Anti-Fraud Association. Performs other duties as required. |
POSITION QUALIFICATIONS Minimum Education: AAS or BA/BS in Criminal Justice or related field required.
Minimum Experience: 5 years insurance claims investigation or professional investigation experience with law enforcement agencies required. Leadership/management experience required. Experience leading and conducting FWA investigations required. Experience working with law enforcement agencies.