Manager Special Investigation Unit
Manager Special Investigation Unit
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Not Disclosed
Salary Not Disclosed
1 Vacancy
Job Description
Key responsibilities include managing vendor relationships overseeing regulatory reporting and implementing new investigative programs and FWA training initiatives. The SIU Manager collaborates closely with the Director to establish program priorities set strategic goals and align departmental objectives with broader organizational initiatives.
Additionally the SIU Manager represents the organization at state and federal task force meetings serving as a key liaison with regulatory bodies law enforcement agencies and other external stakeholders.
Essential Functions - Manager Special Investigation Unit
- Effectively manage the day-to-day operations of the Special Investigation Unit (SIU) ensuring timely and thorough investigation of potential fraud waste and abuse (FWA) cases. Provide coaching mentoring and training to SIU staff and deliver FWA training to key departments across the organization
- Direct and oversee a broad range of investigations and audits related to FWA including medical and pharmacy claims as well as concerns involving members agents and employer groups. Ensure accurate documentation summarization and reporting of findings.
- Implement and continuously refine audit plans to proactively identify FWA risks. Ensure all investigative and audit activities comply with applicable regulatory and compliance standards.
- Serve as a point of contact for external entities such as the U.S. Attorneys Office Office of Inspector General (OIG) state regulators CMS and provider organizations. Respond to inquiries and coordinate information sharing related to FWA investigations.
- Cross-departmental collaboration: Partner with internal departments such as compliance. legal claims provider and others as needed to support enterprise wide FWA mitigation strategies and audit support.
- Review and manage departmental policies procedures and job aids to ensure alignment with regulatory requirements. Provide feedback on provider agreements member materials and other internal documents that impact the fraud and abuse program.
- Monitor and evaluate changes to government program requirements providing feedback and recommendations to ensure compliance and program integrity
- Interpret audit results and assist health plan leadership in developing and implementing appropriate corrective actions to address identified risks.
- Required Bachelors Degree Healthcare Nursing or Business
- 10 years of relevant experience fraud and abuse experience or equivalent combination of; auditing healthcare fraud and abuse compliance or regulatory (i.e. CMS & Medicaid) experience Required
- 5 years of relevant experience An in-depth understanding of provider payment methodologies and concepts (DRGs capitation RBRVS payments APC percent of charges etc.) Required
- 5 years of relevant experience Management experience Required
- 7 years of relevant experience Experience working with government programs including Medicare Medicaid and FEHB Required
- 5 years of relevant experience Well versed with Michigan regulations related to insurance fraud and abuse Preferred
- Understanding and experience with SIU key performance indicators Preferred
- 5 years of relevant experience Direct experience in hospital or physician billing or equivalent experience with a managed care payer. Preferred
- Preferred
- CRT-Accredited Health Care Fraud Investigator (AHFI) - NHCAA National Health Care Anti-Fraud Association preferred
- CRT-Coding Specialist Certified-Physician Based (CCS-P) - AHIMA American Health Information Management Association preferred Or
- CRT-Professional Coder - AAPC American Academy of Professional Coders preferred Or
- CRT-Coding Specialist (CCS) - AHIMA American Health Information Management Association preferred Or
- CRT-Registered Health Information Administrator (RHIA) - AHIMA American Health Information Management Association preferred Or
Physical Demands - Manager Special Investigation Unit
- Pallet to Waist (6 from floor) > 5 lbs: Seldom up to 10 lbs
- Waist to Waist > 5 lbs: Seldom up to 10 lbs
- Waist to Chest (below shoulder) > 5 lbs: Seldom up to 10 lbs
- Waist to Overhead > 5 lbs: Seldom up to 10 lbs
- Bilateral Carry > 5 lbs: Seldom up to 10 lbs
- Unilateral Carry > 5 lbs: Seldom up to 10 lbs
- Pushing Force > 5 lbs: Seldom up to 10 lbs
- Pulling Force > 5 lbs: Seldom up to 10 lbs
- Sitting: Frequently
- Standing: Occasionally
- Walking: Occasionally
- Forward Bend - Standing: Seldom
- Forward Bend - Sitting: Occasionally
- Trunk Rotation - Standing: Seldom
- Trunk Rotation - Sitting: Occasionally
- Reach - Above Shoulder: Seldom
- Reach - at Shoulder or Below: Seldom
- Handling: Occasionally
- Forceful Grip > 5 lbs: Seldom
- Forceful Pinch > 2 lbs: Seldom
How Corewell Health cares for you
Comprehensive benefits package to meet your financial health and work/life balance goals. Learn more here.
On-demand pay program powered by Payactiv
Discounts directory with deals on the things that matter to you like restaurants phone plans spas and more!
Optional identity theft protection home and auto insurance pet insurance
Traditional and Roth retirement options with service contribution and match savings
Eligibility for benefits is determined by employment type and status
Primary Location
SITE - Priority Health - 1231 E Beltline - Grand RapidsDepartment Name
PH - Special Investigations UnitEmployment Type
Full timeShift
Day (United States of America)Weekly Scheduled Hours
40Hours of Work
8:00 a.m. to 5:00 p.m.Days Worked
Monday to FridayWeekend Frequency
N/ACURRENT COREWELL HEALTH TEAM MEMBERS Please apply through Find Jobs from your Workday team member account. This career site is for Non-Corewell Health team members only.
Corewell Health is committed to providing a safe environment for our team members patients visitors and community. We require a drug-free workplace and require team members to comply with the MMR Varicella Tdap and Influenza vaccine requirement if in an on-site or hybrid workplace category. We are committed to supporting prospective team members who require reasonable accommodations to participate in the job application process to perform the essential functions of a job or to enjoy equal benefits and privileges of employment due to a disability pregnancy or sincerely held religious belief.
Corewell Health grants equal employment opportunity to all qualified persons without regard to race color national origin sex disability age religion genetic information marital status height weight gender pregnancy sexual orientation gender identity or expression veteran status or any other legally protected category.
An interconnected collaborative culture where all are encouraged to bring their whole selves to work is vital to the health of our organization. As a health system we advocate for equity as we care for our patients our communities and each other. From workshops that develop cultural intelligence to our inclusion resource groups for people to find community and empowerment at work we are dedicated to ongoing resources that advance our values of diversity equity and inclusion in all that we do. We invite those that share in our commitment to join our team.
You may request assistance in completing the application process by calling 616.486.7447.
Required Experience:
Manager
Employment Type
Full-Time
