| POSITION PURPOSE: |
The Compliance Manager – Fraud, Waste, and Abuse reports to the Director of Compliance. The Manager's primary responsibility is to create, oversee, and structure the components of a mature fraud program in accordance with ACFE standards and best practices. Accountable for anti-fraud leadership, training and awareness, prevention programs, investigative oversight and measuring and reporting on results. The Manager is responsible for building and maintaining a network of contacts for assessing processes, using analytic techniques, and identifying fraud prevention opportunities across IEHP. The Manager is also responsible for recruiting, mentoring, and developing staff, as well as supporting them in their career objectives. The Manager maintains responsibility for validating evidence and communicating internally on case results. Responsible for creating the Fraud Subcommittee and building collaborative relationships with Human Resources, Security, Information Technology, Claims, Pharmacy, Utilization Management, Finance, and Fraud, Waste, and Abuse with an aim towards driving organizational improvement.
• Based on knowledge gained through prevention programs, investigative caseload and industry best practices, create fraud recommendations for process and control improvements and perform follow-up to assess implementation and effectiveness.
• Creates both short and long-term goals for the overall fraud program that align with the vision of a mature fraud program and fit appropriately into the strategic direction of IEHP. Research, develop and maintain policies, program guidelines, practices, templates and tools to assist in meeting standards and staying up-to-date with emerging fraud detection and prevention practices.
• Develop strategies to prevent known frauds or suspected fraudulent activities by working with a variety of IEHP leadership on techniques to prevent, detect and reduce opportunities by creating a stronger control environment. Using industry knowledge, develop strategies in high risk departments for fraud awareness and prevention: Pharmacy, Claims, and Provider Services.
• Ensures accurate and complete representation of investigations, prevention and analytics analyses completed as part of the overall fraud program. Present to the Compliance Committee updates in addition to utilizing relationships and standing meetings to showcase the work and benefit of the fraud team.
• Fraud Prevention: Create and maintain a list of possible data mining techniques to assess and prevent fraud across the organization, continually reassess and prioritize based on new learnings and the growth in the organization. Review results of current and future data mining efforts to ensure appropriate follow through and assess continuation efforts and frequency of review based on historical results.
• Initiates, participates in, and leads departmental and organizational special projects. Possesses advanced public speaking / presentation skills and is comfortable leading meetings, including explaining issues to management and executives and handling constructive disagreements to resolution. Provides constructive feedback to staff leadership activities as needed.
• Investigative Oversight and Evidence Validation: Utilizing the Compliance team and other professionals assigned to cases, make recommendations on how to handle cases as they are identified and ensure resolution to appropriate closure for reduced risk to the organization.
• Leadership: Develops and maintains professional working relationships with department leaders to provide and develop fraud intelligence and collaborate on new initiatives. This would include Human Resources, Security, Information Technology, Claims, Pharmacy, Utilization Management, Fraud, Waste, and Abuse as well as developing new networks and collaborative teams. Provide administrative guidance on all aspects of an effective fraud program, maintain effective organization of fraud activities and cultivate a continual process improvement process in all fraud work.
• Leads and facilitates investigations that may require extensive organization across multiple departments. Ensures that the investigation proceeds according to appropriate policies and procedures. Coordinates staff interviews with Human Resources and the investigation team. May also participate in interviews, as necessary.
• Proactively guides staff on their performance, career guidance, and is able to train investigators/analysts on appropriate tools and techniques of fraud work. Provides timely completion of performance reviews on staff and proactively reviews goals for all fraud personnel, including those without a direct reporting relationship. Responsible for maintaining fraud program job descriptions, understanding fraud in the healthcare industry, and evaluating and selecting applicants for open positions.
• Program Reporting: Successfully manages many competing demands, all delivered within reasonable timeframes and within budgeted hours, and completes and monitors the completion of annual and long-term goals. Monitors and reports on staff productivity and informs leadership of project statuses.
• Training and Awareness: Maintain and update routine staff and manager training modules, currently established as an online module and live training, respectively. Identify, develop and provide focused training in specific high risk areas based on industry research and organizational understandings based on fraud risk.
• Create and utilize the fraud subcommittee to advance techniques used by the fraud team through focused training and cross functional learning on various subjects.
• Validate sufficient and accurate evidence gained and organized for completed cases and review summary documents showing background, work performed and results of each case. Possesses advanced skills relating to interviewing techniques, maintaining an evidentiary chain of custody, and documenting investigative results in an organized, coherent manner.