Special Investigations Unit (SIU) Senior Manager
Apply NowCompany: UCare
Location: Minneapolis, MN 55407
Description:
ABOUT UCARE
UCare offers Medicare, Medicaid, Individual and Family health plans - powered by the hardest working people in the industry. Our people powered teams de-complicate, advocate and always go the extra mile to help our members. We serve with integrity, compassion and commitment to do right by members, providers and government partners. Above all, we come to work excited to provide members a path for the best health of their lives.
WORKING AT UCARE
Working at UCare is more than a career; it's a mission. A mission that defines us as professionals, unites us as an organization and shapes how we interact with our members and each other. Employees join UCare and stay because of the opportunity to have a purpose-driven job.
Our strong culture has established UCare as a Star Tribune Top 200 Workplace for 15 consecutive years since the awards program began. It's a culture that embraces innovative ideas, strategic partnerships, and exemplary customer and provider experiences. Working at UCare is being a part of a people powered team dedicated to making a real difference in the lives of our members and communities.
Position Description
As the Special Investigations Unit (SIU) Senior Manager, you will be responsible for leading the Special Investigations Unit's (SIU) efforts to prevent, detect and resolve suspected Fraud, Waste and Abuse (FWA) by providers and/or enrolled members. You will identify opportunities to strengthen the efficiency and effectiveness of SIU's program integrity and serve as the liaison for UCare's legal team and external authorities. Responsibilities include but are not limited to: program development and management that applies industry expertise and strategic direction in healthcare FWA; managing staff; providing direction and oversight of investigations; data mining analysis; auditing/monitoring activities; and mandatory regulatory reporting.
Education
Bachelor's degree in business, criminal justice, health care or related field. Demonstrated experience may be considered in lieu of degree.
Required Experience
At least five years of managerial experience with at least five years' experience as a professional investigator, in health care fraud, waste, and abuse including Medicaid and Medicare products. Experience testifying in civil, criminal, or administrative proceedings. Working knowledge of local, state, and federal laws and regulations pertaining to insurance, medical terminology, and coding. At least two years of experience analyzing claims data in Excel (or a similar program). Minimum of intermediate level Excel skills.
Preferred Experience
Experience analyzing health care claims data. Experience using health care fraud analytics software such as Healthcare Fraud Shield. Experience with database programming language such as SQL or Python for data buildouts related to FWA investigations. Knowledge of project management and/or process improvement methodologies.
THE UCARE DIFFERENCE
The UCare difference is our people power - employees actively working on the behalf of our members to get them access to the health care they need. We value and respect each individual's ideas and contributions, and provide the freedom to grow both personally and professionally. We are centrally located, and offer onsite education, equipment and wellness resources, and a myriad of volunteer activities. If you're looking for an inclusive environment that celebrates your people power, helps you build on your strengths and gives you the opportunity to truly make a difference, we invite you to apply.
JOB POST DATE: 11/12/2024
UCare offers Medicare, Medicaid, Individual and Family health plans - powered by the hardest working people in the industry. Our people powered teams de-complicate, advocate and always go the extra mile to help our members. We serve with integrity, compassion and commitment to do right by members, providers and government partners. Above all, we come to work excited to provide members a path for the best health of their lives.
WORKING AT UCARE
Working at UCare is more than a career; it's a mission. A mission that defines us as professionals, unites us as an organization and shapes how we interact with our members and each other. Employees join UCare and stay because of the opportunity to have a purpose-driven job.
Our strong culture has established UCare as a Star Tribune Top 200 Workplace for 15 consecutive years since the awards program began. It's a culture that embraces innovative ideas, strategic partnerships, and exemplary customer and provider experiences. Working at UCare is being a part of a people powered team dedicated to making a real difference in the lives of our members and communities.
Position Description
As the Special Investigations Unit (SIU) Senior Manager, you will be responsible for leading the Special Investigations Unit's (SIU) efforts to prevent, detect and resolve suspected Fraud, Waste and Abuse (FWA) by providers and/or enrolled members. You will identify opportunities to strengthen the efficiency and effectiveness of SIU's program integrity and serve as the liaison for UCare's legal team and external authorities. Responsibilities include but are not limited to: program development and management that applies industry expertise and strategic direction in healthcare FWA; managing staff; providing direction and oversight of investigations; data mining analysis; auditing/monitoring activities; and mandatory regulatory reporting.
- Responsible for the strategic direction of SIU and leveraging the FWA risk assessments in order to create and monitor the annual FWA work plan.
- Responsible to ensure SIU remains compliant with all state and federal requirements, including, but not limited to: policies and procedures, regulatory and operational reporting, fulfillment of subpoenas and Requests for Information (RFIs).
- Participate in delegate and vendor contract reviews and negotiations as requested by senior leadership.
- Direct SIU preparedness and audit responses.
- Collaborate with business areas to assist in implementation of overpayment recoveries and corrective action plans for deficiencies identified through investigations, monitoring and auditing activity.
- Oversee SIU operations and conduct high-profile or highly sensitive investigations. SIU operations include the following:
- Collect, review and analyze case evidence such as patient charts, business records, financial ledgers and claims data. Perform analysis of applicable regulations, contracts and policy manuals to determine whether violations exist.
- Conduct interviews of witnesses and/or targets and perform field work including provider site visits and surveillance, as needed.
- Write investigative reports summarizing evidence, investigative activities, and findings. This includes compiling accurate case file documentation and calculation of overpayments. Make referral of findings to law enforcement and/or regulators as appropriate.
- Conduct data mining and data analysis using available tools and internal data warehouse. This includes basic to intermediate functionality in Excel or similar software, performing data manipulation, sorting, analysis, summarization and presentation of data to an understandable and reliable format.
- Prepare and submit required FWA reporting to regulatory agencies, the Compliance Oversight Committee and the Compliance Committee of the UCare Board of Directors.
- Direct SIU staff in managing workload, assigning tasks, monitoring progress against annual FWA work plans and meeting regulatory timelines, bringing forth issues to Legal, and the Vice President, Chief Compliance & Ethics Officer. This includes assisting in the development and oversight of staff training, development plans, monitoring performance and coaching employees.
- Coordinate with law enforcement and/or, government agencies in joint investigations of suspected FWA, serving as an SIU subject matter expert for court testimony, affidavits, and with regulators.
- Coordinate with delegates and contracted vendors in the investigation of suspected FWA.
- Analyze trends and take steps, in collaboration with internal partners, to prevent recurrence. Serve as a resource for departments to research and resolve Program Integrity inquiries and assist in identification of improvements to internal practices that may reduce or prevent FWA. Recommend viable technological solutions, modification, and application to support anti-fraud efforts.
- Maintain an understanding of current state and federal insurance statutes, regulations, and internal policies to ensure compliance.
- Participate in the development and delivery of FWA training for UCare employees as well as any required training for first tier and downstream entities.
- Support the initiatives of the Corporate Compliance Department, leveraging cross functional subject matter expertise to improve the overall effectiveness of UCare's Compliance Program.
- Other projects and duties as assigned.
Education
Bachelor's degree in business, criminal justice, health care or related field. Demonstrated experience may be considered in lieu of degree.
Required Experience
At least five years of managerial experience with at least five years' experience as a professional investigator, in health care fraud, waste, and abuse including Medicaid and Medicare products. Experience testifying in civil, criminal, or administrative proceedings. Working knowledge of local, state, and federal laws and regulations pertaining to insurance, medical terminology, and coding. At least two years of experience analyzing claims data in Excel (or a similar program). Minimum of intermediate level Excel skills.
Preferred Experience
Experience analyzing health care claims data. Experience using health care fraud analytics software such as Healthcare Fraud Shield. Experience with database programming language such as SQL or Python for data buildouts related to FWA investigations. Knowledge of project management and/or process improvement methodologies.
THE UCARE DIFFERENCE
The UCare difference is our people power - employees actively working on the behalf of our members to get them access to the health care they need. We value and respect each individual's ideas and contributions, and provide the freedom to grow both personally and professionally. We are centrally located, and offer onsite education, equipment and wellness resources, and a myriad of volunteer activities. If you're looking for an inclusive environment that celebrates your people power, helps you build on your strengths and gives you the opportunity to truly make a difference, we invite you to apply.
JOB POST DATE: 11/12/2024