Special Investigations Unit (SIU) Director

Portland, TX - USA

Monthly Salary: Not Disclosed

Posted on: 20 hours ago

Vacancies: 1 Vacancy

Job Summary

Join Martins Point Health Care - an innovative not-for-profit health care organization offering care and coverage to the people of Maine and beyond. As a joined force ofpeople caring for people Martins Point employees are on amission to transform our health care system while creating a healthier community. Martins Point employees enjoy an organizational culture of trust and respect where our values - taking care of ourselves and others continuous learning helping each other and having fun - are brought to life every day. Join us and find out for yourself why Martins Point has been certified as a Great Place to Work since 2015.

Position Summary

The Director Special Investigations Unit (SIU) reports to the General Counsel and Chief Legal Officer and leads the Martins Points Audit & Recovery team. Responsible for developing and implementing a fraud waste and abuse program encompassing a wide range of investigations audits and medical code editing scenarios including but not limited to appropriate oversight of Martins Points risk adjustment activities. Ensures all audits and investigations are performed and documented in compliance with applicable federal and state fraud waste and abuse (FWA) guidelines.
Establishes and maintains direct relationship with key internal and external stakeholders including regulators governmental investigatory agencies and Martins Points provider network. Coordinates and oversees vendors and external resources responsible for audit and recovery activities. Collaborates with Compliance Internal Audit and Legal to ensure coordination of activity and smart use of internal resources. Contributes to a culture of compliance with applicable laws and regulations corporate citizenship and diversity equity inclusion and belonging.

Job Description

Key Outcomes:

Accountable for the overall supervision planning organization and execution of MPHCs fraud waste and abuse program.
Leads manages and supports the activities of the Audit & Recovery team to ensure accurate and timely audits and investigations.
Conducts risk adjustment oversight activities and participates in risk adjustment governance structure.
Interprets audit results and assists health plan executives in the development of appropriate action plans to address identified issues including but not limited to financial recovery efforts.
Monitors oversees and evaluates vendors performing audit and recovery activities.
Identifies and directs the implementation of qualified personnel with appropriate expertise improved processes and new technologies.
Ensures compliance with all state and federal regulations for fraud waste and abuse including but not limited to reporting obligations.
In collaboration with Legal responds to all legal inquiries including subpoenas and court appearances.
Attends federal (CMS and/or DHA) and state fraud meetings and industry events and training.
Prepares reporting for business teams Executive Management Team and the Board of Directors.
Coordinates MPHCs participation in FWA/SIU industry associations coalitions and stakeholder groups leveraging participation in those organizations to support MPHPs program.
Builds and maintains strong relationships with federal and state regulators investigatory units and enforcement agencies.
Helps lead a culture of compliance with applicable laws and regulations corporate citizenship and diversity equity inclusion and belonging.

Education/Experience

Bachelors degree in Accounting Criminal Justice Finance Medical Professional Economics Operations Management or related field or equivalent.
Juris Doctor or other applicable advanced degree preferred.
10 years of related compliance FWA and/or special investigation experience in managed care or CMS.
Risk Adjustment experience/expertise preferred.
Track record of progressive leadership responsibilities and achievements as well as significant team management experience.
Significant experience partnering with cross-functional teams.

Required License(s) and/or Certification(s):

CFE PCI or CCJS certification preferred.

Skills/Knowledge/Competencies (Behaviors):

Proven capacity to operate in matrixed organizations across all levels of leadership and in support of different business areas.
Command of current health care FWA issues at the federal and state level and deep knowledge of regulatory requirements and processes.
Knowledge and integrity consistent with the companys values and ability to be a trusted partner to leadership and internal stakeholders.
Executive presence that engenders confidence from federal and state regulators and investigative agencies.
Excellent judgment poise and strong negotiation skills.
Highly advanced communication skills and comfortable making cogent high impact presentations to audience of all sizes and types that motivate action; ability to effectively write for impact.
Proactive problem-solving a track record of persuasive advocacy and strong organizational and time management skills.
Demonstrated ability to handle matters of a sensitive and confidential nature and the capacity to maintain composure while working under pressure.

This position is not eligible for immigration sponsorship.

We are an equal opportunity/affirmative action employer.

Martins Point complies with federal and state disability laws and makes reasonable accommodations for applicants and employees with disabilities. If a reasonable accommodation is needed to participate in the job application or interview process to perform essential job functions and/or to receive other benefits and privileges of employment please contact

Do you have a question about careers at Martins Point Health Care Contact us at:

Required Experience:

Director