Manager of Special Investigations Unit (SIU) (43913)

Neighborhood Health Plan of Rhode Island•Smithfield, RI

12d

About The Position

The Manager of Special Investigations Unit (SIU) is responsible for developing, overseeing and managing the Special Investigations Unit (SIU) department to align with regulatory and/or contractual requirements which combines the responsibilities and activities of provider audit(s), fraud waste and abuse (FWA) and program integrity. This position oversees the intake and tracking of all new alleged complaints/incidents of FWA, assigns cases and manages caseloads to investigative and auditing staff, assists in formulating investigative action plans, engages and partners with internal and external business partners that support FWA activities, coordinates activities with Federal and State law enforcement and regulatory agencies, manages and assists in the development and maintenance of processes and procedures necessary to effectuate the SIU functions, and sets priorities based on current SIU actions and staffing assignments.

Requirements

Bachelor’s degree in business, Criminal Justice, Medical/Healthcare or related field; or a minimum of five (5) + years of relevant work experience in lieu of a degree
Minimum of five (5) years investigative or health plan/health care operations experience
Good working knowledge of regulatory requirements/standards
Superior written and oral communications
Excellent quantitative and analytic skills
Ability to build and maintain relationships internally and externally – across business units, and with State and Federal regulatory agencies
Ability to lead others to achieve desired results in a cross-functional environment, including (but not limited to):
Ability to assess individual performance and communicate assessments effectively
Ability to identify and effectively and efficiently resolve employee performance issues
Ability to establish goals and assist others to achieve goals and meet expectations
Ability to lead others to improve work processes
Previous experience conducting compliance monitoring and audit reviews
Demonstrated ability to effectively prioritize and execute tasks in a high-pressure environment and meet contractual timelines
Proficient with learning & using various technology software tools, including Microsoft Office

Nice To Haves

Direct/indirect supervisory experience

Responsibilities

Ensure SIU staff log and thoroughly document all provider audit and FWA complaints, incidents and leads
Provide coordination to all SIU team members on recommendations and further actions and/or resolution to support investigative needs
Create partnerships with other departments to create and maintain process flows for provider audit, FWA and program integrity functions
Manage and organize meetings with providers, employees, business partners and where appropriate, representatives from regulatory agencies and law enforcement in conduct of investigations and on-site audits
Maintain effective lines of communication with Compliance Officer, Compliance Committee, Legal Counsel and other applicable individuals as required, providing regular updates on all FWA issues with escalation, as needed
Review and assist SIU staff in preparation of assessments and audits, case summaries and detailed reports, as needed
Manage all SIU outbound reporting activities and ensures regulatory and other timelines are met
Develop and maintain contacts/ liaison with law enforcement, regulatory agencies, task force members, other SIU staff, and other external contacts involved in fraud investigation, detection and prevention
Engage in on-going performance management of staff including coaching, mentoring, development, training and succession planning to include hiring and termination decisions
Handle people-related tasks involving new talent, employee engagement, and career development
Other duties as assigned
Corporate Compliance Responsibility - As an essential function, responsible for complying with Neighborhood’s Corporate Compliance Program, Standards of Business Conduct, applicable contracts, laws, rules and regulations, policies and procedures as it applies to individual job duties, the department, and the Company. This position must exercise due diligence to prevent, detect and report unlawful and/or unethical conduct by fellow co-workers, professional affiliates and/or agents